CC: Fever and confusion
HPI: The patient is an 82 year old female with past pertinent medical record of a recent CVA
with residual right-sided deficits, dysphasia, and HTN, who presents to the emergency
department wit
...
CC: Fever and confusion
HPI: The patient is an 82 year old female with past pertinent medical record of a recent CVA
with residual right-sided deficits, dysphasia, and HTN, who presents to the emergency
department with new onset confusion and a fever. The patient was previously hospitalized for
five days following a CVA, which left the patient with right-sided deficits, and dysphasia. Speech
therapy currently has her on a soft food diet, as she will cough with eating if she does not eat
slowly. She has been at a rehab facility for ten days following the recent hospitalization, and she
has actively been working with physical therapy until yesterday. She refused her physical
therapy yesterday, had a poor appetite, developed a cough, dyspnea, and she began to have a
low-grade temperature of 99.6 degrees fahrenheit. As of this am, the patient was able to discuss
details with her morning nurse; however, by 3:00pm she was confused, mumbling, and unable
to answer questions. The patient was found to have a temperature of 101 degrees fahrenheit,
and she was tachycardic at 120 bpm. The patient was transported to the hospital due to these
changes.
Onset:
Location:
Duration:
Characteristics:
Associated signs and symptoms:
Timing:
Exacerbating/ relieving factors:
Current Medications:
Allergies: NKDA
PMHx: CVA with right sided deficits, HTN, and dysphagia. Current on Pneumovax, influenza,
shingles, and influenza vaccines.
Soc Hx: Never smoked or used smokeless tobacco. Does not drink alcohol.
Fam Hx: Widowed with three healthy adult children. Daughter is the POA. Father lived to the
age of 96, and then died in his sleep. Mother died of a CVA complications at 86 years old. No
siblings
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