You just got on shift. A 24 YOA Native-American male presents with fever, chills, malaise, anorexia, and weight loss that has lasted 2 weeks.
History:
Past Medical History: Denies.
Past Surgical History: Tonsillectomy at age 10.
Medications: Denies.
Social History: Denies tobacco or alcohol use. States he does not have a permanent residence: “I sleep around on my friends’ couches.” Admits that he smokes marijuana occasionally, but that: “I haven’t partied in a while.”
Family History: Mother has DM Type 2 and cirrhosis of the liver. The father also has DM Type 2 and has had an MI.
ROS:
Constitutional: Admits to fever, malaise, anorexia, and weight loss. He states that he lost 10 lbs. in the last week.
Neuro: Denies numbness, tingling, weakness, or loss of consciousness. He has generalized weakness.
Pulmonary: Complains of SOB with a cough, but no sputum production. Admits to some pleuritic pain. No hemoptysis.
Cardiac: Denies chest pain. Denies palpations or edema.
GI: Admits to some nausea, vomiting, and diarrhea.
Physical Examination Findings:
Vital Signs: Temp: 39.9, HR 126, BP 84/40, RR 22, O2 Sat 87% on 4LNC.
Lab Values: WBC count is 24.
ABG: 7.25, PO2 is 78, PCO2 is 30, and HCO3-is 11.
Imaging: Chest CT with contrast reveals multiple round densities and cavitations with hilar adenopathy in the lung tissue.
General Status: Patient is ill-kempt. He is cachectic. He appears older than his stated age. He presents moaning on a stretcher.
HEENT: Dry mucous membranes. Exhibits a 2cm linear R forehead laceration, healing with sutures.
Neurological Status: Lethargic. Confused. Opens eyes only with deep sternal rub. Does not follow commands. Moves all extremities 3/5.
Pulmonary Status: Diminished throughout.
Cardiovascular Status: S1 and S2 clear with tachycardia noted, regular rhythm. Pulses 2+ bilaterally in radial, femoral and pedal pulses. Systolic murmur noted. No edema noted.
Skin: Multiple areas of bruising and wounds of various sizes and stages of healing in bilateral antecubital fossae, and between the toes on both feet. Painful, erythematous, raised lesions are found bilaterally on both hands and feet.