Chief Complaint: Weakness
History of Present Illness
A 68 y.o. male comes to the office complaining of fatigue and weakness, which started approximately 1 month ago. Initially, the patient thought he might have a virus, but he became concerned when the symptoms persisted. He sleeps 9 hours at night and takes one to two 1-hour naps each day. He states he just can’t stay awake and reports his sleep is restorative. He has noticed mild general weakness, which is non-focal. He notices this mostly when he has tried to keep up his regular weightlifting routine at the gym.
Past Medical History
HTN, 20 years poorly controlled on Toprol XL 100 mg daily
Overweight– BMI 26
Family History
Father, died at age 75 from complications of CABG
Mother, 92, alive, overall good health, HTN, A-fib, osteoporosis
Psychosocial History
Retired. Married with two grown children. Nonsmoker; drinks one to two glasses of wine almost daily with dinner.
Review of Systems
General: Has lost a few pounds since his appetite is not very good.
HEENT: Denies visual changes; recent eye exam showed no change in prescription. Denies sore throats, frequent colds, hearing difficulties.
CV: BP in fair control. Admits to needing more aerobic exercise. Denies palpitations.
Respiratory: Denies SOB, cough, pneumonia, use of/need for inhalers.
GI: Appetite poor. Denies nausea/vomiting/diarrhea/constipation.
GU: Reports nocturia. Last PSA normal.
Neuro: Denies HAs, dizziness, confusion, although admits to being forgetful.
Endocrine: Denies polyphagia, polyuria (except at night), polydipsia. Denies hair thinning, cold intolerance, weight gain, bradycardia.
Psych: Denies history of depression in family or self.
Physical Examination
Vital signs: BP 170/96, HR 88, RR 14, BMI 26.
General: Alert and cooperative, posture erect, gait study, in no distress.
HEENT: Thick gray hair. Facial expressions symmetrical, PERRLA, EOMs parallel, full peripheral vision. Some AV nicking seen with ophthalmoscopy. Posterior pharynx without lesions, inflammation. No cervical lymphadenopathy. Thyroid not enlarged or nodular. Weber showed no lateralization and Rinne AC greater than BC.
CV: RR&R, no murmurs, S3 or S4. No JVD. No carotid bruits. LE edema 2+.
Respiratory: Clear A&P. CXR showed no cardiomegaly, pneumonia, or other consolidations, effusions, cavitary lesions, or flattening of the diaphragm.
Abdomen: Protuberant. No tenderness, masses, bruits. No shifting dullness.
MS: Strength equal, 5/5 in all four extremities.
Neuro: A&O x 4. CNs II to XII intact. DTRs 2+ bilaterally, negative Romberg
Case Study Discussion – Part I:
Identify three conditions that you would consider in your differential diagnosis, with the most likely condition listed first. Provide rationale for each differential with supporting evidence from the case study.
What diagnostics should be considered in order to explore your differential diagnosis and confirm your suspicions?
1 a Heart Failure-In this condition patients often complaints of waking up tired and swelling of the feet or weight gain.The patient also feels lack of appetite.These are all the symptoms exhibited by the patient in the case study which is similar to a patient having heart failure.
2 Blood tests for sodium,potassium,albumin,creatinine ,Chest Xrays AP a well as lateral to detect whether the heart is enlarged and to see whether there is congestion in the lungs.ECG to check for arrythmias .Inorder to test hearts ejection fraction ,Echo test is also performed.After performing this tests we will will be able to finally conclude with the diagnosis of heart failure.
Chief Complaint: Weakness History of Present Illness A 68 y.o. male comes to the office complaining...
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Week 4 Case Study 66 unread replies.66 replies. Chief Complaint: Rash History of Present Illness A 24 y.o. male presents for a pre-employment physical and mentions a rash on his chest. He noticed the rash last night and says it is “very itchy.” He has not noticed any other skin changes. Overall, he feels well without any accompanying symptoms. He is a teacher and spent most of last weekend doing yard work. Past Medical History Allergic rhinitis Denies surgeries or...
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