07/01/2016 Chart reviewed. Called by Dr., patient's blood pressure has been dropping during ED course despite IV fluid boluses, otherwise her vital signs are stable. Decision made to place central line and start vasopressors, broaden antibiotics to treat presumed sepsis. IMPRESSION: 56 year old female with fever, leukocytosis starting about 12 hours after pneumococcal vaccination. Now with progressive hypotension, unclear if there is a septic source vs anaphylaxis from delayed hypersensitivity reaction vs cardiogenic source. Need to treat presumptive sepsis, admit to ICU. PLAN: 1. NEURO: Stable, prn pain meds. Continue celexa for depression. 2. RESP: Appears stable, monitor closely for evidence of anaphylaxis. Will have prn epinephrine available. 3. CARDIAC/Hemodynamics: Elevated troponin, though minimal, no prior known coronary artery disease. Now needing pressors, though type of shock is unclear. 4. Hypotension: Will start levophed for goal sBP > 90, MAP > 65. 5. Start empiric steroids for possible early anaphylaxis / delayed hypersensitivity reaction. 6. Elevated troponin: Follow serial trops, check echocardiogram in am. 4. INFECTIOUS DISEASE: Unclear possible infectious source. Will continue vanco and ceftriaxone for now pending cultures. 5. HEME: Significant leukocytosis, appears reactive. Also with normocytic anemia, appears stable from prior baseline.. Follow CBC in AM. 6. RENAL: Appears stable, monitor. 7. GI: stable. 8. ENDOCRINE: Check thyroid studies. 9. FEN. 1. Fluid: Given 4 liter bolus, will have LR at 100 ml/hr. 2. Electrolytes: In am. 3. Nutrition: liquids 07/02/2016 This is a 56 y.o. female admitted with fever, leukocytosis and hypotension within about 24 hours of a pneumococcal vaccination.  PLAN: 1. Fevers / leukocytosis / hypotension: Etiology is uncertain, differential remains anaphylaxis / delayed hypersensititivy reaction vs sepsis NOS vs cardiogenic source. She did not require pressors, hypotension resolved with IV fluids. She was given broad-spectrum antibiotics on admission. Echocardiogram within normal limits. 2. Continue empiric ceftriaxone daily until cultures negative for 48 hours 3. Stop solumedrol, continue prednisone 40 mg daily x 3 days, pepcid BID. 4. Leukocytosis: Up to 37 with steroids, will send peripheral smear, suspect neutrophilic predominance. 2. Elevated troponin: Minimal, peaked at 0.07. Echo per above, no further evaluation. 3. Depression: Continue celexa. Transfer from icu at 1400 admitted with fever and hypotension, believe to be an reaction to pneumovax. Has right central line- saline locked. Last Bp 104/59. Afebrile. Feeling better. Speaks another language, son in room will stay the night. On k and mag prot, no replacement needed per report. WBC has been increased to 37.4 today. Being treated for uti until cultures are neg. Antibiotic-Rocephin given. Walking to bathroom with assist. No dizziness when rising. Voiding well. No dysuria. Taking tylenol for pain PRN. Appetite good. Walked in hallway this evening. Lt mid back pain, given Tylenol with relief. Continue POC. Discharged 7/3/16 Hospital Course 1. Fever/hypotension: etiology is uncertain, no clear source found but noted to start within 24 hours after receiving pneunomoccal vaccination. She responded to aggressive IV fluids and empiric antibiotics as well as steroids. Differential remains early anaphylaxis/delayed hypersensitivity reaction vs sepsis NOS. No clear cardiogenic source with normal echocardiogram. She did not require pressors, hypotension resolved with IV fluids. She was discharged on a few days of steroids, no antibiotics at discharge given that they were negative for >48hours.  2. Leukocytosis: unclear etiology, in past she has also had significant leukocytosis. WBC was predominantly neutrophils but up to 37. She did not appear septic or in fact sick after the first day of hospitalization. A peripheral blood smear was sent but pending at time of discharge, though suspect it will show reactive neutrophilia. 3. elevated troponin: minimal, peaked at 0.07. Echo per above, no further evaluation.