“I feel like I got hit by a truck. My body aches intensely, I’m weak, I have a fever, I’m lying under 3 blankets and can’t get warm, and I can’t stop shivering.”
History of Present Illness
AW is a 34-year-old female presenting to the emergency department with a 2-day history of myalgia, chills, and fever to 102°F for which she has been using over-the-counter acetaminophen. She reports a rapid onset of symptoms, including nasal congestion and cough associated with chest pain. She denies a sore throat, but complains of nausea and vomiting that began a few weeks ago and has worsened acutely. She reports 3 episodes of emesis this morning prior to coming to the emergency department. She states she has never received the influenza vaccine, but all of her family members are vaccinated annually.
Asthma, HTN, HLD, hypothyroidism
Father has a history of MI; mother has HTN; sister has a history of breast cancer.
Married with 3 young, healthy children (ages 1, 3, and 6 years). Works as a 7th grade teacher. Denies illicit drug or tobacco use. Drinks alcohol socially.
Penicillin (rash), egg (anaphylaxis)
UTD, refuses influenza vaccine due to egg allergy
Albuterol metered-dose inhaler 2 puffs q4h PRN shortness of breath
Amlodipine 10 mg PO daily
Atorvastatin 20 mg PO daily
Fluticasone-salmeterol 100 mcg/50 mcg 1 puff BID
Levothyroxine 112 mcg PO daily
Temp 101.7°F, P 84, RR 18, BP 136/84 mm Hg, SaO2 97%, Ht 5′5″, Wt 64.5 kg
Lethargic female with headache
Normocephalic, atraumatic, PERRLA, EOMI, pale/dry mucous membranes and conjunctiva
Stridorous breath sounds, equal lung expansion, cough present
RRR, no murmurs, rubs, or gallops
Soft, non-tender, non-distended, normoactive bowel sounds
Warm and well perfused, no edema