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Objectives:
A 33-year-old male presents to the ED complaining of shortness of breath and cough of 10 days duration. He must sleep in a chair due to orthopnea. He also complains of severe fatigue and a mild, diffuse headache. Four days ago, he was seen in an urgent care clinic and diagnosed with bronchitis. Currently, he is taking erythromycin, a cough suppressant, and a decongestant, but he took no medications prior to his diagnosis of bronchitis. He reports no medical problems or surgeries. He quit smoking 1 year ago and denies alcohol and drug use. He has a strong family history of hypertension. The review of systems is otherwise negative.
On physical examination, his temperature is 36.8º C, pulse 104, respiratory rate 16, and blood pressure 200/118. Oxygen saturation on room air is 98%. On chest exam, there are bibasilar crackles with dullness to percussion at the lung bases. The heart, abdomen, and extremities are unremarkable.
His chest x-ray shows cardiomegaly and bilateral small pleural effusions. An EKG shows sinus tachycardia with left atrial enlargement and left ventricular hypertrophy. His laboratory tests are as follows: troponin negative, hemoglobin 9.1 g/dL, WBC count and platelets normal, Na 136 meq/L, K 4.4 meq/L, Cl 96 meq/L, HCO3 19 meq/L, BUN 108 mg/dL, Cr 11.9 mg/dL, glucose 104 mg/dL, calcium 7.8 mg/dL, albumin 4.0 g/dL.
Your patient is admitted. Initially, his urine output increases slightly with loop diuretics, but then he becomes oliguric. You ask for a nephrology consult to assist in management of this case. The nephrologist plans to place an IV catheter for dialysis and is considering a renal biopsy. If the patient develops bleeding with these procedures, he may have difficulty achieving hemostasis.