Thomas Eckert, MD, Junior Assistant Resident in Medicine, the Jewish Hospital of St Louis: An 88-year-old man had a medical history of loss of weight, anorexia, and altered mental status for a month as well as having a fever for three days. He had been hospitalized ten months before for a perforated duodenal ulcer that was plicated. After under-going an operation for the ulcer, a subphrenic abscess developed; it was surgically drained.
Physical examination disclosed an emaciated man who was responsive to painful stimuli only. The patient had a BP of 112/76 mm Hg, a heart rate of 104 beats per minute, respirations of 20/min, and a temperature of 39.2 °C. The patient's mucous membranes were dry; dry rales were noted at the base of the left lung. An abdominal examination disclosed mild, right-upper-quadrant tenderness. Neurologic evaluation showed decreased movement of the right lower extremity to painful stimuli. Deep tendon