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PATIENT PRESENTATION

Chief Complaint

“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.

Past Medical History

CHF, COPD, HTN, epilepsy, stroke, hypothyroidism, anxiety

Surgical History

Hysterectomy, cholecystectomy

Family History

Father had HTN and passed away from a stroke 4 years ago; mother has type II DM and epilepsy; brother has HTN

Social History

Divorced but lives with her two sons who are currently attending college. Smokes ½ ppd × 27 years and drinks alcohol occasionally.

Allergies

NKDA

Home Medications

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

Aspirin 81 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

Physical Examination

Vital Signs

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

General

Lethargic, female with dizziness and in mild to moderate distress.

HEENT

Normocephalic, atraumatic, PERRLA, EOMI, pale or dry mucous membranes and conjunctiva, poor dentition

Pulmonary

Diminished breath sounds and crackles bilaterally.

Cardiovascular

NSR, no m/r/g

Abdomen

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

Genitourinary

Normal female genitalia, no complaints of dysuria or hematuria

Neurology

Lethargic, oriented to place and person, (–) Brudzinski’s sign, (+) Kernig’s sign

Extremities

Pedal edema on lower extremities, petechial lesions on lower and upper extremities

Back

Tenderness to palpation on lower lumbar region

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