A 29-year-old woman presents to the emergency department with fever and tachycardia, 12 years after having had two liver transplants.

1. History

The woman had received two liver transplants in 1999, the first for autoimmune hepatitis and the second for hepatic artery thrombosis. Earlier in the week, she was seen for her annual post-liver transplant evaluation and was found to have a hepatic artery thrombosis, confirmed with CT angiogram the day prior to coming to the emergency department. 

2. Physical examination

On evaluation in the emergency department, she was alert and oriented. She reported recent issues with fatigue, weakness, and abdominal pain. After further questioning, she stated that her fatigue and weakness were more significant within the past two days than in the past. These issues did not affect her activities of daily living. She was still able to work and hold a full-time job.

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Also, she noted her abdominal pain as mild to moderate (3-4 on pain scale from 1 to 10), and that it started two days ago and progressively worsened. She also noted some mild fevers at home for the past two days, characterized as low-grade (99°F to 100°F). She said that she was anxious, and she denied any chills, chest pain, shortness of breath, nausea, vomiting, or any other issues.

Her physical examination was essentially unremarkable, with the exception of a fever of 38.8°C, and tachycardia with a heart rate of 133 bpm. She had some mild abdominal pain with palpation and reported some anxiety regarding coming into the hospital. She also appeared to be mildly dehydrated. Laboratory tests revealed leukocytosis with a white cell count of 12. No lactate was drawn.

3. Plan of care

We discussed her care and what our plan would be, including obtaining blood cultures, urinalysis, and urine culture to rule out infection and giving her IV fluids to treat the mild dehydration, which I noted during her examination. We would watch her for 24 to 48 hours and make sure the cultures were negative; if they became positive we would treat the infection. She appeared anxious to me, and we discussed that. She admitted that she was anxious and did not like being in the hospital. I recommended an anti-anxiety agent if she believed that she needed it. She agreed to this and stated that she felt better after we had talked and knowing our plan. I went back to my day, following up with my other patients and preparing and giving my report to my colleague who was taking over for me in the evening.