Fever Case Study -
Elena is a 74-year-old Hispanic F who was recently discharged one week ago from a local rehabilitation center after status post left hip replacement (one month ago). Negative for any complications. PMH includes HTN, hyperlipidemia and osteoporosis. Today she presents in your office for complaints of a fever, moderate abdominal cramping and pain, and frequent loose stool for the past few days. Her diet has been poor consisting of toast, tea and soup. Positive for mild dizziness, slight headache, nausea. Negative for chills, chest pain, shortness of breath or vomiting. She has been taking advil OTC for abdominal pain, does not remember the dose or how often she has been taking it. States 2 tablets about 2-3 times a day with fair effect. No other OTC medications.
Past Medical History: HTN, hyperlipidemia, osteoporosis, left wrist fracture, vitamin D deficiency and status post left hip ORIF repair.
Social history: widowed, lives in own home, retired florist. 3 children how live close by. Negative smoking hx. Occasional glass of wine on weekends. Born in Haiti and immigrated to US 10 years ago. Visits yearly-last visit was 2 months ago.
Medications: Lisinopril 5 mg daily, atorvastatin 40 mg daily, alendronate10 mg every am.
Allergies: shellfish
ROS: see above, otherwise WNL
PE:
VS: Temp: 101.1 HR: 90 RR: 16 BP: 102/60
General: fatigued appearing, alert and oriented. Gently rubbing abdomen
Skin: left hip incision CDI, negative erythema, jaundice or pallor
HEENT: slightly dry mucous membranes, otherwise unremarkable
LN: negative lymphadenopathy
Respiratory: clear to auscultation, neg adventitious sounds.
Cardiac: regular sinus rhythm, negative rubs, gallops, murmurs
Abdomen: distended, tender to mild palpation of left quadrants, BS hyperactive, negative hepatosplenomegaly.
Any other history to obtain?
Which diagnostic or imaging studies should be considered?
What is your list of differentials?
What is your diagnosis?
What is your plan of treatment? Pharmacological? Non pharmacological?
Any referrals needed?
Please include the following:
a. History and physical that clearly states the pertinent positives and negatives of the case.
b. A problem list
c. A general assessment statement
d. Discussion of differentials OR discussion of the pathophysiology for the key problem
e. An assessment statement for all other problems on problem list not included in "d"
f. A comprehensive plan for all problems and evaluation of differentials.
Attachment:- Assignment Files.rar