Question Answered step-by-step Chief complaint: Pt complains of feeling tired all the time, dizziness upon awakening. HPI: 51 year old male complaining of increasing fatigue over about 2-3months. Feels tired all day, feeling constantly rundown. Denies recent acute illnesses. Dizziness for a second when he gets up too fast. No precipitating events for fatigue. Is not aware of other major symptoms. He is concerned something is wrong but can’t specify a particular concern.Past Medical history:NoneMedications:AllegraAllergies:Seasonal Past surgical historyNone Family history NoneSocial history: Married, no children works as a engineerReview Of System General: 51 year old English speaking male with reduced energy, and dizziness upon awakening.Skin: Denies rashes, lesionsHead: Denies trauma , headache, dizziness, lightheadednessEyes: Denies eye pain ,redness, visual disturbances, excessive tearingEars : Denies hearing loss ,discharge ,tinnitus ,vertigo, pain ,earacheNose: Denies nasal discharge itching , nose bleeds, sinus trouble Mouth and Throat: Denies throat pain, frequent sore throats, denies bleeding gumsNeck : Denies lumps , swollen glands ,neck stiffnessChest: Denies difficulty of breathing , coughs, shortness of breath Heart/Cardiovascular: Denies chest pain, chest tightnessAbdomen: Denies heartburn, constipation, abdominal pain, diarrhea. GU/GYN: deniesMusculoskeletal: denies Neurologic: Denies headache ,+dizziness, light-headedness, numbness, speech difficulty, syncope, tremors, weaknessPsychiatric: denies Endocrine: Denies Hematological: Denies Physical Exam: General Survey: Alert and Oriented x3, well- nourished male Vital signs : B/P 116/66, HR 64, RR 16, Skin: no rash Head: Normacelphac, atraumaticEyes: PEERLA, visual acuity 20/20Ears: External canal patent, tymphanic membrane pearly grey, with good cone of light 5 in right ear and 7 in left ear, rhinne, weber intact.Nose: nasal mucosa pink, moist, no sinus tendernessThroat: anterior tonsils normal in size , no evidence of obstruction in the posterior pharyngeal wall, uvula rises midlineNeck: supple with no thyromegaly, Cardiovascular : S1 and S2, no murmurs , rubs or gallops, no heaves, no liftsPeripheral vascular: pulses 2+Neurovascular : Cranial nerves intact, normal, (-)Romberg (-) pronator drift Identify at least 4 differential diagnoses for this patient based on the history and exam findings?2. Create a plan of care based upon case presentation Health Science Science Nursing NURSING 751 Share QuestionEmailCopy link Comments (0)
Question Answered step-by-step Chief complaint: Pt complains of feeling tired all the time, dizziness upon awakening. HPI: 51 year old male complaining of increasing fatigue over about 2-3months. Feels tired all day, feeling constantly rundown. Denies recent acute illnesses. Dizziness for a second when he gets up too fast. No precipitating events for fatigue. Is not aware of other major symptoms. He is concerned something is wrong but can’t specify a particular concern.Past Medical history:NoneMedications:AllegraAllergies:Seasonal Past surgical historyNone Family history NoneSocial history: Married, no children works as a engineerReview Of System General: 51 year old English speaking male with reduced energy, and dizziness upon awakening.Skin: Denies rashes, lesionsHead: Denies trauma , headache, dizziness, lightheadednessEyes: Denies eye pain ,redness, visual disturbances, excessive tearingEars : Denies hearing loss ,discharge ,tinnitus ,vertigo, pain ,earacheNose: Denies nasal discharge itching , nose bleeds, sinus trouble Mouth and Throat: Denies throat pain, frequent sore throats, denies bleeding gumsNeck : Denies lumps , swollen glands ,neck stiffnessChest: Denies difficulty of breathing , coughs, shortness of breath Heart/Cardiovascular: Denies chest pain, chest tightnessAbdomen: Denies heartburn, constipation, abdominal pain, diarrhea. GU/GYN: deniesMusculoskeletal: denies Neurologic: Denies headache ,+dizziness, light-headedness, numbness, speech difficulty, syncope, tremors, weaknessPsychiatric: denies Endocrine: Denies Hematological: Denies Physical Exam: General Survey: Alert and Oriented x3, well- nourished male Vital signs : B/P 116/66, HR 64, RR 16, Skin: no rash Head: Normacelphac, atraumaticEyes: PEERLA, visual acuity 20/20Ears: External canal patent, tymphanic membrane pearly grey, with good cone of light 5 in right ear and 7 in left ear, rhinne, weber intact.Nose: nasal mucosa pink, moist, no sinus tendernessThroat: anterior tonsils normal in size , no evidence of obstruction in the posterior pharyngeal wall, uvula rises midlineNeck: supple with no thyromegaly, Cardiovascular : S1 and S2, no murmurs , rubs or gallops, no heaves, no liftsPeripheral vascular: pulses 2+Neurovascular : Cranial nerves intact, normal, (-)Romberg (-) pronator drift Identify at least 4 differential diagnoses for this patient based on the history and exam findings?2. Create a plan of care based upon case presentation Health Science Science Nursing NURSING 751 Share QuestionEmailCopy link Comments (0)
