CHALLENGING CLINICAL CASE NO. 12/2001
This is an eighteen year old female who presents with worsening headache and shortness of breath for two days. She notes fatigue and general malaise that has been worsening despite her attempts to rest. She is now short of breath walking around the house. The patient was ill ten days ago with rigors, body aches, fever, and sore throat but this resolved after five days. She had then been well with none of these symptoms until two days ago. She is nauseated with a decreased appetite. If asked she will admit to decreased urine output and a reddish brown urine.
PMHx: Unremarkable. The patient was an athletic, healthy individual.
Social: In senior year of high school, living with parents. Denies ETOH or illicit drug use.
Allergies: None Known
The patient is a well developed, but ill appearing young female. She is in no acute respiratory distress.
BP = 165/115 pulse = 125 rr = 30 temp = 97.8 degrees F (orally)
Room air pulse oximetry = 91%
Skin: Moist with no lesions or rashes
EOMI, PERRL,Funduscopic exam is normal
TM's are clear
Mouth/Pharynx are clear and moist. No evidence of exudate, or swelling
Neck is supple with no masses and a normal thyroid exam.
JVD is present to 2cm above the clavicle with the patient at 45 degrees
Cardiovasc: Tachycardic rate with no rubs, murmurs or bruits
Respiratory: Equal air excursion with rales 1/3 of the way up both lung fields
Abdomen: Normal bowel sounds, no masses
Liver is slightly enlarged and mildy tender
Rectal exam is normal and the patient is negative for occult blood
Pelvic: Normal external genitals, normal exam
Extremities: 2 plus pitting edema of the lower extremities
Neuro: The patient has a non-focal neurologic exam.
ECG: regular sinus tachycardia with a rate of 130. The PR, QRS, QT, and QTc intervals were normal. The T-wave is normal.
Chest radiograph: Acute pulmonary edema
ABG (room air): 7.25; pCO2=19; pO2=80 (metabolic acidosis and respiratory alkalosis).
Na= 135 mEq/L, K=5.5 mEq/L, Cl=105 mEq/L, Bicar=16 mEq/L, BUN=50 mg/dL, creat=4.6 mg/dl, Glu=110 mg/dl. WBC= 15k, Hct 32, Plt = 215
Urine= 3+ protein, large blood, ketones are trace, and there are 20-30 WBC, and 60-70 RBC per high powered field. Red blood cell casts are present.
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