CASE 25: FEVER AND SHORTNESS OF BREATH
History
A 62-year-old man presents to the emergency department complaining of shortness of breath.
Four days prior to presentation he felt unwell and complained of muscle aches and headache.
He started having rigors and his wife measured his temperature as 39°C. They thought that he
had influenza. However his symptoms worsened, and by the day of presentation he was com-
plaining of a dry cough and marked shortness of breath. He had also become confused, and
started having diarrhoea. There is no significant past medical history. He is a non-smoker and
drinks 20 units of alcohol a week. Ten days prior to admission he had returned from a holiday
in Spain.
Examination
On examination the patient looks unwell, dehydrated and flushed. His temperature is 39.5°C.
He has central cyanosis. His pulse rate is 120/min and blood pressure 146/72 mmHg. His
respiratory rate is 32/min. His trachea is central and chest expansion is symmetrical.
Percussion is reduced, and auscultation reveals bilateral crackles and bronchial breathing in
both lower zones posteriorly. His abdomen is diffusely tender but there is no rigidity or guard-
ing. He is disorientated in time, place and person.
Blood tests, arterial blood gases on air, urinalysis and chest X-ray (Fig. 25.1) are shown
below.
NormalHaemoglobin 15.3 g/dL 13.3–17.7 g/dL
White cell count 10.3% 109 /L 3.9–10.6% 109 /L
Neutrophils 8.9% 109 /L 1.8–7.7% 109 /L
Lymphocytes 0.4% 109 /L 0.6–4.8% 109 /L
Platelets 143 % 109 /L 150–440% 109 /L
Sodium 124 mmol/L 135–145 mmol/L
Potassium 4.4 mmol/L 3.5–5.0 mmol/L
Urea 14.4 mmol/L 2.5–6.7 mmol
Creatinine 178 &mol/L 70–120&mol/L
Glucose 7.7 mmol/L 4.0–6.0 mmol/L
Calcium 1.88 mmol/L 2.12–2.65 mmol/L
Phosphate 1.2 mmol/L 0.8–1.45 mmol/L
C-reactive protein (CRP) 256 mg/L !5 mg/L
Arterial blood gases on air
pH 7.38 7.38–7.44
pCO 2 2.7 kPa 4.7–6.0 kPa
pO 2 6.3 kPa 12.0–14.5 kPaUrinalysis:''blood;''protein