A 29-year-old woman presents to the Emergency Department with severe abdominal pain and dyspnea, both of which have been progressive over the past 4 days. She states that her appetite is decreased, and she is feeling lethargic. She had attributed her symptoms to her menstrual period, which was due about the time her symptoms began. She had foul-smelling discharge from her vagina on the morning of presentation, which prompted her to seek medical care. Her dyspnea is described as general breathlessness, without accompanying cough. She admits to being sexually active with several partners in the past 2 months. Her last sexual contact was about one week ago, and involved vaginal intercourse. She uses birth control methods inconsistently. The patient reports a 10 year history of cigarette smoking, approximately 1 pack per day. Her last medical appointment was with her gynecologist 3 weeks previously, when a routine pap smear was performed.

General Appearance: Initially the patient is in no distress. During the physical examination, she becomes tense, her hands and feet become cold and dusky, and she begins shivering. Her blood pressure during this episode falls to 90/50, and her respiratory rate increases to 24/minute. She is febrile (39° C/102.2 F) at the time of examination. Other pertinent physical findings are as follows:

Integument: Diffuse macular erythematous rash.

Head/Eyes/Ears/Nose/Throat: Hyperemic oral mucous membranes and conjunctivae.

Abdomen: Severe suprapubic and abdominal discomfort on palpation. Guarding present.

Genital/Rectal: Vaginal mucosa is very erythematous. Purulent discharge present.

Lymph nodes: Shotty inguinal nodes present up to 2.0 cm, with mild pain on palpation.

Lungs: Crackles present.

Hemoglobin: 12.5 g/dl		normal: 12-14 g/dl
Platelets: 90,000/mm3		normal: 150,000-300,000/mm3
WBC: 18.5 x103/mm3		normal: 4.5-10.5 x103/mm3
WBC differential:
	82% neutrophils	normal: 40-75%
	14% bands	normal: 0-5%
	3% lymphocytes	normal: 20-40%
	1% monocytes	normal: 0-9%
Oxygen saturation 93% on room air

The patient is started on empiric antibiotic therapy, and cultures are obtained for microbiologic identification. Later in the day of her admission, the patient begins to experience progressive dyspnea and a productive cough, consisting predominately of frothy fluid. Her blood pressure continues to remain low despite supportive measures. She goes into cardiopulmonary arrest and expires during the second night of her admission.