Case study I The patient is a E-year-old white female presenting to the emergency department with acute onset shortness of breath. Symptoms began approximatelyr 2 days before and had progressively worsened with no associated, aggravating, or relieving factors noted. She had similar symptoms approximately 1 year ago with an acute, chronic obstructive pulmonary disease {CDPD} exacerbation requiring hospitalization. She uses BiPAP 1irentilatory support at night when sleeping and has requested to use this in the emergency department due to shortness of breath and wanting to sleep . She denies fever, chills, cough, wheezing, sputum production, chest pain, palpitations, pressure , abdominal pain , abdominal distension , nausea , vominng , and diarrhea . She reports difficulty breathing at rest, forgetfulness, mild fatigue, feeling chilled, requiring blankets, increased urinary frequency, incontinence, and swelling in her bilateral lower extremities that are new-onset and worsening. Subsequently, she has not ambulated from bed for several days except to nse the restroom due to feeling weak , fatigued ,and short of breath