Dyspnea, Fever, Hemoptysis, and Diabetes in a Tobacco User

Avnish Sandhu, DO; Pranatharthi Chandrasekar, MD


December 02, 2020

Physical Examination and Workup

Her blood pressure is 110/75 mm/Hg, heart rate is 115 beats/min, and respiration rate is 38 breaths/min. Her temperature is 101.7°F (38.7°C). She is noted to be hypoxic, with an oxygen saturation of 88% on room air. Consequently, a non-rebreather mask is placed on the patient. She remains tachypneic on the non-rebreather mask, requires intubation, and is placed on a mechanical ventilator. Soon thereafter, supraventricular tachycardia develops. She receives two doses of adenosine, and the underlying rhythm is identified as atrial fibrillation.

The physical examination reveals dry oral mucosa with dried blood. Results of the cardiac examination are consistent with tachycardia and irregular rhythm. Upon lung examination, breath sounds are rhonchorous bilaterally, with diminished air entry on the right side. Her abdomen is soft, nontender, and nondistended, with normal bowel sounds and no rebound, guarding, or signs of peritoneal inflammation.

A comprehensive metabolic panel and a complete blood cell count reveal the following findings:

  • Serum creatinine level: 2.13 mg/dL (reference range, 0.7-1.2 mg/dL)

  • Aspartate aminotransferase level: 147 U/L (reference range, 5-30 U/L), with normal alkaline phosphatase and alanine aminotransferase levels

  • White blood cell count: 16 × 109/L (reference range, 4.5-11.0 × 109/L)

  • Hemoglobin level: 15.9 g/dL (reference range, 13.5-17.5 g/dL)

  • Serum lactate level: 4.2 mmol/L (reference range, 0.5-1 mmol/L)

  • Troponin I level: 0.5 ng/mL (reference range, 0-0.4 ng/mL)

  • Blood glucose level: 428 mg/dL (reference range, 74-106 mg/dL)

A CT scan of the chest shows a large area of consolidation in the right lower lobe with trace effusion and bilateral scattered ground-glass opacities (Figures 1 and 2). An ECG reveals atrial fibrillation, a normal axis, and diffuse ST segment elevation (Figure 3).

Figure 1.

Figure 2.

Figure 3.

A transthoracic echocardiogram demonstrates a reduced ventricular ejection fraction of 40%, with increased left ventricular wall thickness and a small pericardial effusion.

A real-time polymerase chain reaction (PCR) assay performed on a nasopharyngeal swab specimen is negative for SARS-CoV-2. Acid-fast bacilli smears from three endotracheal specimens are negative. Blood culture, respiratory culture with Gram staining, and a respiratory viral panel are ordered.

Fluid resuscitation is immediately started, and because of concerns about severe sepsis, therapy is initiated with intravenous vancomycin, ceftriaxone, and azithromycin.


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