07-04-2008, 03:29 AM
A 19-year-old woman is evaluated in the emergency department for persistent cough and progressive dyspnea. Four weeks ago, she developed a nonproductive cough that was treated with two completed courses of oral antibiotics. She has a history of systemic lupus erythematosus treated with azathioprine and prednisone. Three months ago, hemoglobin was 10.1 g/dL (101 g/L), creatinine was 0.9 mg/dL (79.58 µmol/L), and complement levels were normal.
On physical examination, temperature is 38.3 °C (101 °F), pulse rate is 110/min, respiration rate is 18/min, and blood pressure is 150/86 mm Hg. A malar rash is present. Neck veins are not distended. Pulmonary examination reveals bibasilar crackles. On cardiac examination, there is no rub, murmur, or gallop.
Laboratory Studies
Hemoglobin
7.2 g/dL (72 g/L)
Leukocyte count
11,000/µL (11 × 109/L)
Erythrocyte sedimentation rate
92 mm/h
Creatinine
1.3 mg/dL (114.95 µmol/L)
Total bilirubin
1.1 mg/dL (18.81 µmol/L)
Lactate dehydrogenase
537 U/L (8.95 µkat/L)
Haptoglobin
240 mg/dL (2400 mg/L)
Anti“double-stranded DNA antibodies
Titer of 1:320
Serum complement (C3 and C4)
Decreased
Urinalysis
1+ protein; 2+ hematuria; rare erythrocyte casts
Blood cultures
Pending
Echocardiogram shows normal ejection fractions, 1+ mitral regurgitation, and normal systolic and diastolic function. Chest radiograph is shown (Figure 42).
Which of the following is the most likely cause of this patient's dyspnea?
A Alveolar hemorrhage
B Congestive heart failure
C Mitral regurgitation
D Pneumothorax
On physical examination, temperature is 38.3 °C (101 °F), pulse rate is 110/min, respiration rate is 18/min, and blood pressure is 150/86 mm Hg. A malar rash is present. Neck veins are not distended. Pulmonary examination reveals bibasilar crackles. On cardiac examination, there is no rub, murmur, or gallop.
Laboratory Studies
Hemoglobin
7.2 g/dL (72 g/L)
Leukocyte count
11,000/µL (11 × 109/L)
Erythrocyte sedimentation rate
92 mm/h
Creatinine
1.3 mg/dL (114.95 µmol/L)
Total bilirubin
1.1 mg/dL (18.81 µmol/L)
Lactate dehydrogenase
537 U/L (8.95 µkat/L)
Haptoglobin
240 mg/dL (2400 mg/L)
Anti“double-stranded DNA antibodies
Titer of 1:320
Serum complement (C3 and C4)
Decreased
Urinalysis
1+ protein; 2+ hematuria; rare erythrocyte casts
Blood cultures
Pending
Echocardiogram shows normal ejection fractions, 1+ mitral regurgitation, and normal systolic and diastolic function. Chest radiograph is shown (Figure 42).
Which of the following is the most likely cause of this patient's dyspnea?
A Alveolar hemorrhage
B Congestive heart failure
C Mitral regurgitation
D Pneumothorax