“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.
CKD [baseline SCr 1.1 (3 days prior)]
HTN [baseline BP 124/76 mmHg (3 days prior)]
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)
Negative for tobacco, alcohol, and illicit drug use.
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
Temp 99.7°F, P 120, RR 18, BP 88/56 mmHg, pO2 94 % Ht: 5′9″, Wt: 72 kg
Appears stated age, in mild distress, pale and diaphoretic.
Normocephalic, atraumatic, PERRLA, EOMI, dry mucus membranes and conjunctiva, no neck stiffness/pain, no photophobia.
Soft, non-distended, nontender to palpation, bowel sounds hyperactive.