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PATIENT PRESENTATION

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

Allergies

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″

General

Responsive, intubated, appears well nourished

HEENT

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

Respiratory

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

Cardiovascular

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

Abdominal

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

Genitourinary

Foley catheter in place. Moderate suprapubic tenderness

Skin/Extremities

Dry, no rash. No peripheral edema

Neurology

Pupils equal and reactive, alert and oriented ×2

Laboratory Findings

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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: 15.9 sec

ALT: 24 IU/L

SCr: 3.0 mg/dL

INR: 1.2

T bili: 2.0 mg/dL

Glu: 140 mg/dL

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