Case Challenge #15

History of Present Illness

A 42-year-old white female presented with a history of high-grade fever and yellow productive cough for one day. The cough is associated with pleuritic chest pain and shortness of breath at rest. This is the 2nd episode in the last year. The patient describes chronic dyspnea for approximately 15 years limiting her ability to perform household activities. A review of systems was significant for chronic fatigue and weakness for 15 years, and chronic loose stools with occasional constipation for 10 years. Medical history includes COPD and recurrent sinus infections. No smoking history. Her mother also had COPD and recurrent sinus infections. Medications included levalbuterol, montelukast, fluticasone/salmeterol.

Physical Exam

  • T 99.8°F, HR 137/min, BP 109/59 mmHg, RR 26/min,  98% sat
    • Bibasilar rhonchi
    • No clubbing or nasal polyps
    • Remainder of the physical examination was within normal limits.

Labs/Imaging

  • WBC 15,800, Cr 1.0
  • ABG: pH 7.5, PC02 32 mmHg, PO2 78 mmH,  HCO3 25 mEq/l
  • Chest X-ray: bibasilar infiltrates  on 2 l/min nasal oxygen
  • CT chest without contrast: bronchial wall thickening and dilatation predominantly in the lower lung fields consistent with bronchiectasis

Question