Chief Complaint: Hemophysis
a. History: Progressive shortness of breath over the past few weeks with dry cough and intermittent fever.
b. Further History: Persistent nasal congestion and sinusitis. He has experienced weight loss of 12 lb over this time.
| Pivotal Assessment | Finding |
|---|---|
Additional History |
Weight loss |
A previously healthy 67-year-old man presents to the emergency department after coughing up blood. He describes progressive shortness of breath over the past few weeks with dry cough and intermittent fever. He has been seen in the clinic several times over the past few months for persistent nasal congestion and sinusitis. The nasal and sinus symptoms have not responded to antibiotics. He has experienced weight loss of 12 lb over this time. On the morning of presentation, the cough became productive of bloody sputum. The patient estimates that he has produced 2 tablespoons of blood over the past 6 hours.
Temperature is 37.5°C; heart rate, 103 beats per minute; blood pressure, 110/30 mm Hg; and respiratory rate, 28 breaths per minute. Breathing appears labored. There is marked depression of the midportion of the nasal bridge. There are multiple red-purple papules ranging from 5 mm to 2 cm in diameter with some areas of confluence over the shins and ankles. There is diffuse expiratory wheezing.
Serum creatinine is 1.9 mg/dL. Evaluation of urine sediment reveals the presence of dysmorphic red blood cells and red blood cell casts. Serum antibodies to PR3 (c-ANCA) are present. Computed tomography (CT) imaging of the chest is shown in Figure 58-1.