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PATIENT PRESENTATION

Chief Complaint

“I am coughing and very short of breath.”

History of Present Illness

UL is a 47-year-old Caucasian male who presents to the emergency department via EMS with complaints of recent onset of fevers, shortness of breath, cough, and pleuritic chest pain. The patient reports that his symptoms began 3 days ago when he woke up in the middle of the night with shortness of breath and noticed sharp right-sided chest pain. The chest pain was provoked primarily by deep inspiration, and he was not able to go back to sleep. Last night, he began developing worsening chills, and also began to have wheezing and progressive shortness of breath. He also developed a productive cough, bringing up thick sputum eventually culminating in an episode of dry heaving and emesis. He states his emesis was originally dark blood, and toward the end of throwing up had some flecks of bright blood mixed in.

When EMS arrived at his home, UL was hypoxic (70% O2 sat), tachypnic (RR 30), and tachycardic (HR 110s). He was administered nebulized albuterol and ipratropium and 1 L normal saline on the way to the hospital.

Past Medical History

Lupus erythematosus (inactive since 1992), coronary artery disease, deceased donor renal transplant 1994 secondary to lupus nephritis, CKD 4 (GFR 15-29); baseline SCR 2.5-3 mg/dL

Surgical History

Renal transplant 1994

Family History

Father has HTN and type 2 DM; mother alive and well

Social History

Married and lives with wife. No history of smoking or illicit drug use; drinks alcohol occasionally

Allergies

NKDA

Home Medications

Cyclosporine (Neoral®) 75 mg PO each morning, 50 mg PO each evening

Mycophenolate mofetil 500 mg PO twice daily

Prednisone 5 mg PO daily

Cholecalciferol (Vitamin D3) 1,000 units PO twice daily

Sodium bicarbonate 650 mg PO twice daily

Furosemide 20 mg daily as needed for swelling

Physical Examination

Vital Signs

Temp 102.2°F, P 110, RR 24, BP 136/78 mm Hg, pO2 95%, Ht 5′6″, Wt 62.4 kg

General

Middle-aged, thin gentleman in no acute distress

HEENT

Anicteric sclera, pale conjunctiva, erythematous posterior oropharynx. Neck supple without lymphadenopathy

Pulmonary

Inspiratory rales most prominent anterolaterally on both sides, few rales posteriorly

Cardiovascular

NSR, no m/r/g

Abdomen

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

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