Sehrish W.almost 5 years ago

A 28-year-old man comes to the emergency room complaining of 6 days of fevers with shaking chills. Over the past 2 days, he has also developed a productive cough with greenish sputum, which is occasionally blood streaked. He report no dyspnea, but sometimes experiences chest pain on deep inspiration. He does not have headache, abdominal pain, urinary symptoms, vomiting, or diarrhea. He has no significant past medical history. He does smoke cigarettes and marijuana regularly, drinks several beers daily, but he denies intravenous drug use. Present symptom: sthenic fever, flushed face, cough without sticky sputum, poor appetite, restless and yellow urine, red tongue with deep yellow coating, rapid and racing pulse. On examination, his temperature is 102 5 F , with a heart rate of 109 bpm, blood pressure of 128 /76 mmHg , and a respiratory rate of 23 breaths per minute . He is alert and talkative. He has no oral lesions and his funduscopic exam reveals no abnormalities. His jugular veins show prominent V waves, and his heart is tachycardic but regular with a harsh holosystolic murmur at the eft lower sternal border that increases with inspiration . His chest exam reveals inspiratory rales bilaterally. On both of his forearms, he has linear streaks of induration, hyperpigmentation, with some small nodules overlying the superficial veins, but no erythema , warmth , or tenderness . Laboratory examination is significant for an elevated white blood cell ( WBC )count at 17 500 / mm3 with 84% polymorphonuclear cells , 7% band forms . and9% lymphocytes, a hemnoglobin concentration of 14 g / dL , a hematocrit of 42% and a platelet count of 189 000 / mm . Liver function tests and a urinalysis are normal. His chest radiograph shows multiple peripheral, ill-defined nodules , some with cavitation 1. What is the most likely diagnosis, and why ?