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PATIENT PRESENTATION

Chief Complaint

“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.

Past Medical History

Asthma, HTN, HLD, hypothyroidism

Surgical History

Appendectomy 6 years ago

Family History

Father has a history of MI; mother has HTN; sister has a history of breast cancer.

Social History

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.

Allergies

Penicillin (rash), egg (anaphylaxis)

Vaccines

UTD, refuses influenza vaccine due to egg allergy

Home Medications

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

Montelukast 10 mg PO QHS

Physical Examination

Vital Signs

Temp 101.7°F, P 84, RR 18, BP 136/84 mm Hg, SaO2 97%, Ht 5′5″, Wt 64.5 kg

General

Lethargic female with headache

HEENT

Normocephalic, atraumatic, PERRLA, EOMI, pale/dry mucous membranes and conjunctiva

Pulmonary

Stridorous breath sounds, equal lung expansion, cough present

Cardiovascular

RRR, no murmurs, rubs, or gallops

Abdomen

Soft, non-tender, non-distended, normoactive bowel sounds

Genitourinary

Deferred

Neurology

Lethargic, AAO ×3

Extremities

Warm and well perfused, no edema

Skin

No rashes, or lesions

Laboratory Findings

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