“I have severe headaches and fevers.”
History of Present Illness
DJ is a 54-year-old Caucasian female who presents to the emergency department with worsening headache, neck pain, and back pain of 2 days duration. She also complains of low-grade fevers and chills that developed over the past 24 hours. Her son, who is present during her exam, states that she seems more lethargic and has difficulty maintaining her balance. In addition, she reports 3 to 4 episodes of nausea and vomiting.
CHF, COPD, HTN, epilepsy, stroke, hypothyroidism, anxiety
Father had HTN and passed away from a stroke 4 years ago; mother has type II DM and epilepsy; brother has HTN
Divorced but lives with her two sons who are currently attending college. Smokes ½ ppd × 27 years and drinks alcohol occasionally.
Advair 250 mcg/50 mcg 1 puff BID
Albuterol metered-dose-inhaler 2 puffs q4h PRN shortness of breath
Alprazolam 0.5 mg PO daily
Atorvastatin 20 mg PO daily
Carvedilol 6.25 mg PO BID
Citalopram 20 mg PO daily
Divalproex sodium 500 mg PO BID
Furosemide 20 mg PO daily
Levothyroxine 88 mcg PO daily
Levetiracetam 500 mg PO BID
Lisinopril 20 mg PO daily
Temp 101.2°F, P 72, RR 23 breaths per minute, BP 162/87 mm Hg, pO2 91%, Ht 5′3″, Wt 56.4 kg
Lethargic, female with dizziness and in mild to moderate distress.
Normocephalic, atraumatic, PERRLA, EOMI, pale or dry mucous membranes and conjunctiva, poor dentition
Diminished breath sounds and crackles bilaterally.
Soft, non-distended, non-tender, bowel sounds hyperactive
Normal female genitalia, no complaints of dysuria or hematuria
Lethargic, oriented to place and person, (–) Brudzinski’s sign, (+) Kernig’s sign
Pedal edema on lower extremities, petechial lesions on lower and upper extremities
Tenderness to palpation on lower lumbar region