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PATIENT PRESENTATION

Chief Complaint

Headache, fevers, and chills

History of Present Illness

GR is a 68-year-old woman with a notable past medical history of rheumatoid arthritis on infliximab and a prosthetic aortic valve, who was brought to the emergency department (ED) after her family found her extremely lethargic and confused at home. She had been complaining of fevers, chills, headache, and neck pain for 2 days prior to presentation, and as per the patient’s family had steadily become less and less communicative. Otherwise the patient has had no major medical issues in the last year since her aortic valve replacement.

Past Medical History

CAD, depression, type II DM, eczema, HTN, fibromyalgia, severe aortic stenosis with valve replacement

Surgical History

Bioprosthetic aortic valve replacement (10 months ago), S2–S4 diskectomy (4 years ago), tubal ligation (>15 years ago), cholecystectomy (>15 years ago)

Family History

Father passed away from HF; mother has type II DM, HTN, and h/o stroke; sister has type II DM, COPD, and HTN

Social History

Widowed, lives by herself, never used alcohol, former smoker (quit 10 years ago)

Allergies

Hydrocodone/acetaminophen (vomiting)

Home Medications

Aspirin DR tablet 81 mg PO daily

Atorvastatin 20 mg PO daily

Fluoxetine 40 mg PO daily

Glimepiride 4 mg PO daily

Infliximab 3 mg/kg IV every 2 months

Lisinopril 10 mg PO daily

Pregabalin 75 mg PO BID

Triamcinolone 0.1% lotion topical BID

Vitamin D3 5,000 IU PO daily

Physical Examination

Vital Signs

Temp 102.1°F (tympanic), HR 112 bpm, RR 19 breaths per minute, BP 91/52 mm Hg, SpO2 97% (on room air), Ht 165 cm, Wt 91 kg, BMI 33.4 kg/m2

General

Lethargic, acutely ill appearing, appears stated age

HEENT

Normocephalic, atraumatic, PERRLA, EOMI, faint conjunctival hemorrhage, non-icteric sclera, poor dentition, no erythema or swelling in the oropharynx

Neck

No nuchal rigidity, tenderness to palpation on lower lumbar region

Pulmonary

Clear to auscultation bilaterally, no wheezes or crackles

Cardiovascular

Regular rate and rhythm, faint systolic murmur over the right base

Abdomen

Soft, non-distended, no masses, no focal rebound or guarding, tenderness in the epigastric region to palpation

Genitourinary

No complaints of dysuria or hematuria

Neurology

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