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PATIENT PRESENTATION

Chief Complaint

“I think I have the flu.”

History of Present Illness

KJ is a 76-year-old African American female who presents to the ED from a senior living community with complaints of vomiting, diarrhea, and feeling unwell. She states that she became ill 4 days prior to admission, and has been vomiting every few hours, having watery diarrhea five times per day, and has body aches and subjective fever. The provider at the senior living community visited her 3 days prior to arrival and instructed her to drink plenty of fluids and take over-the-counter analgesics for aches and pains. However, she states that she has had a poor appetite and has not felt well enough to eat or drink. Other than her maintenance medications, she has been taking two over-the-counter ibuprofen tablets every 4 to 6 hours since her visit with the facility’s provider. She also reports decreased urination, but thinks it is probably due to her poor oral intake.

Past Medical History

T2 DM

CKD [baseline SCr 1.1 (3 days prior)]

HTN [baseline BP 124/76 mmHg (3 days prior)]

GERD

Family History

Mother: T2DM, HLD, HTN, obesity, and died at age 81 from an ischemic stroke

Father: HTN, died in MVA at age 68

Sibling: T2DM, HTN (living)

Social History

Negative for tobacco, alcohol, and illicit drug use.

Immunization

Up to date

Insurance

Aetna PPO

Allergies

No known drug allergies

Home Medications

  • Metformin 1000 mg PO bid

  • Glipizide IR 10 mg PO daily

  • Lisinopril/HCTZ 20 mg/12.5 mg, 2 tablets PO daily

  • Metoprolol succinate 25 mg PO daily

  • Famotidine 20 mg PO twice daily

  • ASA 81 mg PO daily

  • Ibuprofen 400 mg PO every 4–6 hours as needed for pain or fever

Physical Examination

Vital Signs

Temp 99.7°F, P 120, RR 18, BP 88/56 mmHg, pO2 94 % Ht: 5′9″, Wt: 72 kg

General

Appears stated age, in mild distress, pale and diaphoretic.

HEENT

Normocephalic, atraumatic, PERRLA, EOMI, dry mucus membranes and conjunctiva, no neck stiffness/pain, no photophobia.

Pulmonary

CTAB.

Cardiovascular

Tachycardic, no m/r/g.

Abdomen

Soft, non-distended, nontender to palpation, bowel sounds hyperactive.

Genitourinary

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