Skip to Main Content


Chief Complaint

Unable to obtain due to clinical status

History of Present Illness

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.

Past Medical History

Depression, hypertension, chronic kidney disease (baseline SCr 1.9 mg/dL), coronary artery disease—stable angina

Family History

Father passed away at age 80 from a stroke; mother had type 2 diabetes and passed secondary to breast cancer.

Social History

Widowed, lives with her daughter’s family. Drinks alcohol occasionally, never smoker


Penicillin (rash)

Home Medications

Escitalopram 10 mg PO daily

Amlodipine 10 mg PO daily

Labetalol 600 mg PO q8h

Lisinopril 40 mg PO daily

Nitroglycerin 0.4 mg sublingual PRN chest pain

Physical Exam

Vital Signs

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″


Responsive, intubated, appears well nourished


Dry mucous membranes, neck supple, oropharynx clear. Endotracheal tube and nasogastric tube in place


Respirations are unlabored and ventilator dependent. Decreased breath sounds in bilateral bases. No rales


Tachycardic, normal S1-S2, regular rate and rhythm. No murmur, rubs, or gallops


Soft, tender, non-distended, positive bowel sounds in all quadrants


Foley catheter in place. Moderate suprapubic tenderness


Dry, no rash. No peripheral edema


Pupils equal and reactive, alert and oriented ×2

Laboratory Findings

| Download (.pdf) | Print

Na: 136 mEq/L

Hgb: 9.5 g/dL

Ca: 7.2 mg/L

K: 4.9 mEq/L

Hct: 28%

Mg: 2.0 mg/L

Cl: 100 mEq/L

Plt: 90

Phos: 5.5 mEq/L

CO2: 11 mEq/L

WBC: 21.2 × 109/L

AST: 26 IU/L

BUN: 29 mg/dL

PT: ...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.