Case Presentation

A 44 year old female with a past medical history of type 2 diabetes, hypertension, congestive heart failure, coronary artery disease, 2 strokes, 2 myocardial infarctions, questionable history of pulmonary embolus twice, bipolar disorder, schizophrenia, and multiple asthma exacerbations presented to the Emergency Department (ED) with SOB and wheezing. Her symptoms began at home earlier that day and were not improved by bronchodilators. On arrival to the ED, she was lethargic in severe respiratory distress with laboring accessory muscle use. She had only an allergy to latex. Outpatient medications included albuterol inhaler, fluticasone/salmeterol inhaler, inhaled budesonide, furosemide, and warfarin for empiric treatment of an unidentified hypercoaguable disorder. She reported having a 15 pack year smoking history including marijuana and cocaine use up to several days prior to admission, but she denied any prior alcohol or intravenous (IV) drug abuse. Family history was non contributory. Her respiratory distress prohibited a thorough review of systems on admission, but the rest of her history was obtained through family at the time of arrival. They related that she had described some chest tightness earlier.