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CC 49 yo African American male presenting to the ER complaining of shortness of breath

HPI He started feeling short of breath while at dialysis and admits to several months of intermittent productive
cough and night sweats. He also noted that he felt feverish when his vitals were checked before hemodialysis.
He does use O2 at home but only PRN, he has not had to increase its use before presentation. Denies CP, N/V
but does have on/off diarrhea. (**Questionable compliance with home meds)
ROS
CONSTITUTIONAL: as per HPI
HEENT: Eyes: No diplopia or blurred vision.
ENT: No earache, sore throat or runny nose.
CARDIOVASCULAR: No chest pain, palpitations
RESPIRATORY: + cough, shortness of breath, No paroxysmal nocturnal dyspnea or orthopnea.
GASTROINTESTINAL: + diarrhea, No nausea, vomiting
GENITOURINARY: No dysuria, frequency or urgency.
SKIN: No change in skin, hair or nails.
NEUROLOGIC: + weakness, No paresthesias, fasciculations, seizures
PSYCHIATRIC: + Depression, hallucinations, no suicidal/ homicidal ideations
ENDOCRINE: No heat or cold intolerance, polyuria or polydipsia.
HEMATOLOGICAL: No easy bruising or bleeding.

Past Medical History


HIV with AIDS
CAD/ MI x 2 w/ cardiac arrest in 2012
HTN
ESRD on HD M, W, F
Heparin inducted thrombocytopenia
Anemia associated with chronic renal failure
COPD
Left ventricular hypertrophy
PMH extended
HIV with AIDS **Questionable compliance
Last 11/08/2014 CD4 count 5 with viral load of 29,200. Follows at HIV clinic
Candidemia 1/30/2012 1/2 blood cultures positive for Candida albicans; treated
Thrush, oral

Current HAART Therapy


Darunavir 800 mg PO q daily
Etravirine 200 mg PO BID
Raltegravir 400 mg PO BID
Ritonavir 100 mg po q daily

Past surgical hx
Insert Dialysis catheters
Left AV graft placement 5/2/2012
Right brachiocephalic AV fistula placement 11/2012
Right basilic vein transposition 10/2013
Areteriovenous fistula branch ligation
Social History
Tobacco: Current 1ppd x 37 years
EtOH: None
Illicit drugs: Hx of marijuana use
Sexual activity: Several years abstinent

Other home meds


Diltiazem 240 mg PO q daily
ASA 325 mg PO q daily
Famotidine 20 mg PO BID
Furosemide 40 mg PO q daily
Sertraline 25 mg PO q daily
Fluconazole 200 mg PO QOD
Bactrim QOD
Azithromycin 600 mg PO every 7
days
Family Hx
Father- unknown
Mother- HTN
Brother- HTN
Sister- HTN
Allergies
Ace-i: swelling
Heparin- Heperain induced
thrombocytopenia (HIT)

PE
Ht 5' 8" (1.727 m)
Wt 150 lb 9.2 oz (68.3 kg)
Temp(Src) 38.3 C (101 F) (Oral) BP 172/108

BMI 22.90 kg/m2


Pulse 104
Resp 28

SpO2 95%

GENERAL: NAD, A&O, cachectic appearing


NEURO: CN 2-12 grossly intact, no slurred speech or facial droop, no focal abnormalities
HEENT: NCAT, no scleral icterus, no erythema, no conjunctival lesions, moist mucus membranes (MMM), no
notable hearing loss, poor dentition, no oral thrush noted, no masses, thyromegally or lymphadenopathy noted
CV: Rapid rate, regular rhythm, no clicks/rubs/murmurs
PULM: diminished breath sounds in all lung fields BL, worse at BL bases, mild adventitious sounds noted in
upper lobes
ABD: Soft, Non tender non-distended (NTND), Normoactive bowel sounds (BS), no guarding or rigidity
EXT: no clubbing, cyanosis, or edema, BL LE muscle wasting. Pulses were palpable throughout, severe
onychomycosis noted to all toenails
Osteopathic Examination: bilateral thoracic and lumbar paraspinal muscle tightness/tissue texture change

Ca 8.2
Tot Protein 6.1
Albumin 3.0
AST/ALT 35/13
Alk Phos 67
T Bili 0.9
Venous Lactate 1.1
Lactic Dehydrogenase 1697
Blood cultures No growth 2/2 x 5 days

CXR

IMPRESSION:
Bilateral lung opacities likely represent edema. Cannot exclude atypical pneumonia.

Clinical course
Patient meets SIRS criteria and was admitted with diagnosis of sepsis secondary to BL pneumonia
Admitting medications
Bactrim 600 mg IV q daily
Prednisone 40 mg PO BID -> taper
Levaquin 750 mg IV q daily
Cont. home meds as prescribed
Consults on admission
Nephrology for ESRD/ HD
Pulmonology for possible diagnostic broncoscopy
Results of Bronchoalveolar lavage
BAL R middle lobe PCR- negative for MAC
BAL AFB smear- negative
BAL legionalla- negative
BAL KOH prep- negative
BAL fungal culture- pending
Bronchial brush cultures- Rare Staphylococcus, coagulase negative
Viral culture- pending
Pneumocystis smear- POSITIVE

Diagnoses and conclusion- PCP pneumonia.


Levaquin was discontinued after results of BAL were acquired. All other home meds continued as prescribed.
Patient was referred to interventional radiology for placement of tunneled central venous catheter to
complete 21 days of IV Bactrim. He symptomatically improved and his CXR returned to normal after the 4th
week. He was educated on the vital importance of being compliant with his mediation

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