Case 11

51 y o male with pmhx of asthma on 3 L NC at night, renal disease, deafness presents with complaints of acute on chronic SOB, worsening today. Patient had SOB at rest. Patient has never been intubated, no recent admission for asthma and is taking asthma home medications. Patient was sent from PMD for current symptoms for further evaluation. Denies CP, fever/c/n/v/d, abdominal pain, back pain.

ROS:

Constitutional: No fever, chill, myalgias
Cardiac: No chest pain, + SOB
Respiratory: see HPI
Abdomen: no abdominal pain
Skin: b/l LE swelling
Endocrine: no hx of DM 

PHYSICAL:

Vitals:  P: 98 R: 18 BP:218/135 Sat 88% ra T: 97.1 pain: 0
Constitutional:  NAD, speaking in full sentences
ENT: normal pharynx w/o tonsilar hypertrophy
Chest: normal chest excursion with respiration
Cardiovascular: Normal S1 and S2, no M/R/G
Respiratory: moving good air, b/l expiratory wheezes
GI/GU: non-distended, non-tender
Extremities: b/l LE swelling with chronic skin changes, no calf tenderness
Neuro: grossly un remarkable findings
Psychological:  the patient’s mood and manner are appropriate

LABS:

CBC:  WBC:11.96 Hbg; 12.9  Hct: 41.9 Plt: 240
BMP: Na: 137 K: 3.7 Cl: 106 Co2: 24 BUN: 42 Cr: 4.17
Cardiac Enzymes: CK: 245 CKMB: 13.9 Troponins: 0.14
Coags:  PT: 12.2  aPTT: 30.5 INR: 1.1 

1. What is the abnormality present on this picture?