A 44-year-old woman presents to her local emergency department after 5 days of persistent fever, productive cough, and worsening dyspnea on exertion. She also notes that for the past 24 hours she has had an odd skin discoloration. She states that her phlegm is green but denies any blood or dyspnea at rest. She has no other complaints and denies any recent travel or drug abuse.


Vital signs are normal except for a pulse oxygen of 92% on room air. Blood pressure was fine at 144/73 mm Hg and remained in that range on repeat exam. Her physical exam was normal except for diffuse rales and wheezing and the skin changes noted below. There was no edema, and her skin temperature was normal.

Initial Concerns

  • Sepsis
  • DIC
  • Pneumonia
  • Asthma


  • Chest radiograph showed bilateral hazy infiltrates.
  • PT, PTT, and platelets were normal, but the white blood cell count (WBC) was elevated at 19,000.
  • Chemistry values were all normal.

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