History of increasing weakness and malaise

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Reference no: EM133921135

CASE STUDY

Patient: Betty Inkley, 84-year-old female - allergy to penicillin; Height 70 inches, Weight 124 lbs

Chief Complaint: Provided by the patient's in-home caregiver: "Mrs. Inkley is confused and very sick. She was up most of the last night coughing!"

History of Present Illness: Mrs. Betty Inkley is an 84-year-old white female. She lives at home with an in-home caregiver. She uses a walker and takes daily strolls through the park with her caregiver. She is able to perform most ADLs, however, the caregiver prepares all meals.

Her caregiver brought her into the ED with reports of a one-week history of URI symptoms and a two-day history of increasing weakness and malaise. About three days ago, the patient developed a cough that has gradually become worse and she now has difficulty catching her breath. The caregiver also reports that the patient was confused last night and nearly fell while going to the bathroom. The patient has been coughing up a significant amount of phlegm that is thick and green in color. The caregiver has become concerned by the patient's reduction in daily activities and an inability to get rid of her "cold".

Reference no: EM133921135

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