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PATIENT PRESENTATION

Chief Complaint

“I have been coughing, have chest pain, and cannot breathe for about 2 days now.”

History of Present Illness

WA is a 40-year-old Caucasian male who presents to the emergency department with a fever, cough, chest pain (worsening when breathing or coughing), and shortness of breath. Normally, he has a fairly active lifestyle as he trains for marathons. He has not traveled outside the United States recently. He states he has “been taking cough medicine at night” for the past 4 days to help him sleep, but it has not been getting better. Also, he reports that he has been waking up at night due to heavy sweating. He states all his symptoms have gotten worse in the last 2 days. After being assessed in the ED, WA is admitted to the medicine unit for further workup.

Past Medical History

Diabetes: Type 1

Surgical History

N/A

Family History

Father has diabetes: Type 1, history of heart attack; mother has hypertension.

Social History

Married with no kids. Denies smoking and drinks alcohol occasionally (weekends, social events)

Allergies

NKDA

Home Medications

Insulin (bolus/basal: ~35 units total daily)

Aspirin 81 mg PO daily (cardiovascular protection)

Atorvastatin 20 mg PO daily (cardiovascular protection)

Physical Examination

Vital Signs

Temp 100.8°F, HR 110 bpm, RR 30, BP 125/75 mm Hg, p02 93%, Ht 5′9″, Wt 70 kg

General

Slightly lethargic, mild—moderate distress

HEENT

Normocephalic, atraumatic, PERRLA, EOMI, normal mucus membranes and conjunctiva, adequate dentition

Pulmonary

Diminished breath sounds and crackles (rales) bilaterally

Cardiovascular

NSR, no m/r/g

Abdomen

Soft, non-distended, non-tender, bowel sounds hyperactive

Neurology

Lethargic, oriented to place and person, (–) Brudzinski’s sign, (–) Kernig’s sign

Extremities

No significant findings

Vaccines

States he cannot remember all of them. He says he received all his age-related vaccines when younger. Has not received his flu-shot this year as he always forgets to receive it.

Laboratory Findings

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Na = 148, mEq/L

Hgb = 14 g/dL

Ca = 8.5 mg/dL

K = 4.3 mEq/L

Hct = 38%

Mg = 2.3 mg/dL

CL = 115 mEq/L

Plt = 300 × 103/mm3

Phos = ...

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