79-Year-Old Woman With Dyspnea, Cough, and Renal Failure

Resident in Internal Medicine, Mayo School of Graduate Medical Education, Jacksonville, FL (N.J.P., M.E.W.); Advisor to residents and Consultant in Hospital Internal Medicine, Mayo Clinic, Jacksonville, FL (M.C.B.). A 79-year-old woman presented to the hospital from a rehabilitation facility with worsening dyspnea, nonproductive cough, and fever. Immediately before admission to the rehabilitation facility, she was hospitalized at an outside hospital for 1 month for evaluation of fever, chills, and malaise. During that hospitalization, she aspirated stomach contents, and pneumonia subsequently developed, which was treated with a 7-day course of intravenous vancomycin, piperacillintazobactam, and levofloxacin. Her hospitalization was further complicated by acute kidney injury after contrast computed tomography. Bilateral lower extremity deep venous thrombosis developed and was being treated with enoxaparin. A peripherally inserted central venous catheter and urinary catheter were placed during the hospitalization and removed before discharge. Three days after admission to the rehabilitation facility, the patient experienced dyspnea, a nonproductive cough, chest discomfort, and fever. The family reported that she was urinating several times daily. On admission to our hospital, the patient was afebrile and had a pulse rate of 89 beats/ min, respiratory rate of 24 breaths/min, blood pressure of 152/81 mm Hg, and oxygen saturation of 96% while receiving 15 L of oxygen via nonrebreather mask. She appeared frail and in moderate respiratory distress. Examination revealed 2-cm jugular venous distention above the sternal notch. She had decreased breath sounds in the right lower lobe, bibasilar crackles, and bronchial breath sounds in the upper airways. There was a 3/6 holosystolic murmur at the apex that radiated to the left axilla and 3þ left-sided and 2þ right-sided pretibial edema. She had normal bowel sounds and lower abdominal tenderness without guarding or rebound. There was no lymphadenopathy. Laboratory studies yielded the following results (reference ranges provided parenthetically): hemoglobin, 12.1 g/dL (12.0-15.5 g/dL); mean corpuscular volume, 84.1 fL