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18 YEAR OLD PATIENT REASON FOR ENCOUNTER : PASSED OUT WEEK 7 I HUMAN CASE (CLASS 6512) CASE 2025 18 YEAR OLD PATIENT REASON FOR ENCOUNTER : PASSED OUT WEEK 7 I HUMAN CASE (CLASS 6512) CASE 2025
Typology: Exams
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1. Patient Information (Expanded) Age : 18 years old. Gender : Male. Height : 6’0” (183 cm). Weight : 222.0 lbs (100.9 kg). BMI : Calculate to assess whether obesity is a factor. o BMI = Weight (kg) / Height² (m²). Chief Complaint : Passed out (syncope). Context of Syncope : o Where was he (e.g., standing, sitting)? o Was the episode witnessed? o Any associated trauma during the event? Other Patient Demographics to consider: Race/ethnicity (if relevant to hereditary conditions). Occupation/student (to assess stress, fatigue, or sleep deprivation). 2. History Questions (Expanded)
History of Present Illness (HPI): Detailed exploration of the syncope episode:
Any known medical conditions (e.g., hypertension, diabetes, arrhythmias)? Previous diagnoses of seizures or neurological conditions? Medications and Allergies: Are you currently taking any prescription medications, over-the- counter drugs, or supplements? o Focus on diuretics, antihypertensives, or antidepressants. Any recreational drugs or excessive caffeine/alcohol consumption? Known allergies? Family History (FH): Is there a family history of: o Heart disease or arrhythmias? o Sudden cardiac death at a young age? o Neurological disorders (e.g., epilepsy)? Social History (SH): Do you consume alcohol, tobacco, or other substances? Are you under stress, sleep-deprived, or experiencing emotional disturbances? Physical activity level and diet quality? Review of Systems (ROS):
General : Weight loss, fever, fatigue. Cardiovascular : Palpitations, chest pain, leg swelling. Neurological : Headache, weakness, confusion, memory loss. Endocrine : Polyuria, polydipsia (signs of diabetes). Psychiatric : Anxiety, depression.
3. Physical Exam (Expanded) General Appearance: Does the patient appear pale, anxious, or diaphoretic? Is he alert and oriented? Vital Signs: Blood pressure (supine, sitting, and standing to assess for orthostatic hypotension). Heart rate and rhythm. Respiratory rate and oxygen saturation. Temperature (if infection suspected). Focused Examination: 1. Cardiovascular Exam: o Check heart rate, rhythm, and murmurs (e.g., aortic stenosis). o Auscultate for signs of heart failure (e.g., S3 gallop). o Assess for peripheral pulses and edema. 2. Neurological Exam: o Cranial nerve function, motor strength, reflexes, sensation, and coordination.
o Test for nystagmus or gait instability.
Primary Diagnoses to Consider:
Follow-Up and Referrals: Schedule follow-up with a cardiologist or neurologist. Educate the patient about warning signs and when to seek immediate care. Subjective: Identifying Information: Age: 18 years Gender: Male Height: 6'0" (183 cm) Weight: 222.0 lb (100.9 kg) BMI: [To be calculated, approximately 30.5 (indicates obesity)] Chief Complaint (CC): "I passed out." History of Present Illness (HPI): The patient reports that he lost consciousness earlier today. He states the following: He was standing in line for a prolonged period before fainting. Felt lightheaded and nauseated before passing out. No preceding chest pain, shortness of breath, or headache. Episode lasted less than a minute, and he regained consciousness spontaneously without confusion. No reported tongue biting or involuntary movements during the episode. He hit his elbow during the fall but denies head injury or significant trauma.
First episode of this kind. Associated Symptoms: No fever, fatigue, or recent weight loss. No palpitations or irregular heartbeats. No visual changes or neurological deficits. Past Medical History (PMH): No history of syncope, seizures, or cardiac conditions. No diagnosed chronic illnesses. Medications: None reported. Allergies: None known. Family History (FH): No family history of heart disease, arrhythmias, or sudden cardiac death. No family history of epilepsy or neurological disorders. Social History (SH): Non-smoker. Does not drink alcohol or use recreational drugs. High school student with moderate stress levels from academics. Reports a sedentary lifestyle and frequent consumption of fast food. Review of Systems (ROS): General: No fever, chills, or recent illness.
Cardiovascular: No chest pain, palpitations, or edema. Neurological: No weakness, numbness, or confusion. Endocrine: No excessive thirst or urination. Psychiatric: No depression or anxiety reported. Objective: Vital Signs: Blood Pressure: 118/76 mmHg (supine), 96/64 mmHg (standing) — positive orthostatic hypotension. Heart Rate: 82 bpm (supine), 96 bpm (standing). Respiratory Rate: 16/min. Temperature: 98.6°F (37°C). Oxygen Saturation: 98% on room air. General Appearance: Alert, oriented, appears well-nourished, but mildly anxious. No acute distress. Focused Physical Examination:
o Strength 5/5 in all extremities. o Normal reflexes. o No focal deficits or signs of postictal confusion.
o Educate the patient on lying down if lightheadedness occurs again. o Advise adequate hydration and electrolyte replenishment.
Discussed red flag symptoms such as chest pain, persistent palpitations, or recurrent fainting episodes, requiring immediate medical attention.