The Case

CC

Fever and cough

HPI

59yF HIV on ART last CD4 716, undetectable VL, HTN, CKD p/w non-productive cough and fever x10d. 5d PTA she presented to the ED for dry cough, had CXR WNL, lab values WNL except Cr 3.2 and was discharged with f/u. Symptoms have continued since and she returns now because she has dyspnea at rest x 1d. Also c/o fatigue, chills and loose stools. She denies chest pain, headache, change in vision, rash, sick contacts or recent travel.

PMH / PSH

PMH: CKD, HTN, HIV
PSH: none
Meds: HAART, losartan, spirinolactone, chlorthalidone, crestor, clonidine, amlodipine
NKDA

Physical Exam

BP 120/70 HR 104 Resp 20s Sat 92% on 2LNC Temp 102.9F
General: tachypneic but in NAD
HEENT: NCAT, EOMI, PERRL, dry mm
CV: tachy, no m/r/g
Pulm: CTA throughout, but tachypneic on 2L O2
Abdomen: protuberant, soft, nondistended, no ttp, rebound or guarding
Neuro: Awake, alert, oriented, normal strength, sensation, coordination
Ext: normal active ROM, no deformities or edema
Skin: no diaphoresis, rashes, or lesions. Warm and dry.

Questions

  1. What is your differential for this patient? What’s at the top of your list?

  2. What are the next steps in management of this patient and your anticipated disposition?

  3. What one lab test would you send, if you had to clinch the diagnosis?