Posted by Vivian Hayashi MD and Robert Smith MD, Mystery Quiz Section Editors
The patient is a 42 year old male non-smoker with history of poorly controlled asthma (first diagnosed in 1994, recurrent need for steroid treatments but never intubated), severe seasonal allergies with chronic sinusitis, hepatic steatosis, GERD and gout who presented with complaints of five to ten days of myalgias, productive cough, wheezing and chest tightness. His medications included albuterol, fluticasone and formoteral inhalers, montelukast, colchicine, indomethacin prn, and fexofenadine. Exam was significant for T 97.6, HR 100, BP 120/83, RR 22, O2Sat 95% on RA. The patient was moderately obese, appeared anxious and tachypneic but speaking in full sentences. Heart exam was within normal limits with no JVD. Lung exam with decreased breath sounds and scattered inspiratory and expiratory wheezing throughout. No rales nor rhonchi. Labs were significant for WBC 12.0 with 75% polys, 12.7% lymphs, 8.4% eos; mild transaminitis (ast/alt 48/89—patient’s baseline). Blood cultures pending x 2.
Admission CXR: Images 1 & 2