What Would You Do?
A 52-year-old woman presents to the emergency department with a 1- to 2-day history of fever, right flank pain, and nausea. Vital signs are: temperature 39.1 °C (102.4 °F), heart rate 130 beats/min, respiratory rate 22 breaths/min, and blood pressure 70/40 mm Hg. She has right costovertebral angle tenderness. Laboratory findings are: WBCs 15 × 103/μL, creatinine 1.9 mg/dL, and lactate 3.5 mmol/L. Urinalysis reveals many WBCs and few RBCs. CT reveals right hydronephrosis with an obstructing ureteral stone. She receives 2 L lactated Ringer solution and is started on norepinephrine and broad-spectrum antibiotics. Blood and urine cultures are pending. Urology plans intervention once the patient is stabilized. Despite increasing norepinephrine to 0.25 µg/kg/min, blood pressure remains low at 80/50 mm Hg.