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Unable to obtain due to clinical status
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History of Present Illness
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JG is a 72-year-old woman who was brought to the emergency department by her daughter when she noticed the patient was more confused than her baseline and was found to have a high fever with rigors. The daughter notes that the patient had complained of fatigue and back/abdominal pain accompanied by nausea and vomiting 4 days prior to presentation. JG developed respiratory distress in the emergency department and required intubation.
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Depression, hypertension, chronic kidney disease (baseline SCr 1.9 mg/dL), coronary artery disease—stable angina
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Father passed away at age 80 from a stroke; mother had type 2 diabetes and passed secondary to breast cancer.
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Widowed, lives with her daughter’s family. Drinks alcohol occasionally, never smoker
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Escitalopram 10 mg PO daily
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Amlodipine 10 mg PO daily
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Lisinopril 40 mg PO daily
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Nitroglycerin 0.4 mg sublingual PRN chest pain
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Temp 39.4°C; BP 86/50 mm Hg; MAP 62; HR 123; RR 24 breaths per minute; O2 sat 90% on 50% FiO2, qSOFA = 3, Wt 68 kg, Ht 5′ 4″
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Responsive, intubated, appears well nourished
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Dry mucous membranes, neck supple, oropharynx clear. Endotracheal tube and nasogastric tube in place
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Respirations are unlabored and ventilator dependent. Decreased breath sounds in bilateral bases. No rales
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Tachycardic, normal S1-S2, regular rate and rhythm. No murmur, rubs, or gallops
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Soft, tender, non-distended, positive bowel sounds in all quadrants
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Foley catheter in place. Moderate suprapubic tenderness
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Dry, no rash. No peripheral edema
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Pupils equal and reactive, alert and oriented ×2
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