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COMPREHESIVE CASE WEEK #7 (CLASS 6512) 18 YEAR OLD PATIENT REASON FOR ENCOUNTER: PASSED OUT I HUMAN CASE 2025 INCLUDING ALL CLINICAL CASE REPORT Documentation"
Typology: Assignments
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Week 7 iHuman Assignment – 18 year old male 6’0” 220 lbs. Reason for encounter: Passed out “I passed out at football practice. My trainer thinks its because of the heat index being 100 and that I didn’t drink enough. We have a big game tomorrow so I just need to make sure I can play.” Senior in high school When did you pass out? – Just today Did you hit your head? Did you lose consciousness? – A few seconds LOC. How were you feeling prior to passing out? – During our afternoon practice we ran our 2 mile laps and I noticed that I was struggling and my legs were hurting. All of the sudden I seemed to lose my hearing, noticed my vision changed. It was like just black and white, no color, then it coned down to a pinhole and next thing I remember, I am down on the track looking up at the trainer. Any preceding symptoms or aggravating factors? – No shortness of breath before fainting. Muscles have been sore this week from working out. How did you feel when you regained consciousness? Did not feel confused. Everyone was standing around me and looking at me. It took my a few seconds to recognize where I was. I didn’t remember falling, but after they told me I remembered the weird feeling leading up to the fall, I guess. I wasn’t out for long. Severity – Did you feel any pain? Was the episode witnessed? – Yes. Dad (Ken Brown) reports that when he got to the field it had just happened. The trainer said that she noticed he had just stopped, stumbled a bit, and then went down. All happened about an hour ago. Have you ever passed out before? No first time today. Patient reports sweating like crazy today.
Do you have any ongoing medical issues? Only allergies and the things that were told to patient at last visit. Any previous surgeries or hospitalizations? No medical, surgical, or dental procedures. Any allergies? Seasonal stuff, like grass and mold makes him sneezing and have a runny nose, which is much worse in the fall. Any past injuries? (concussions, sprains, or broken bones) Are you taking any medications (prescription, over the counter, dietary supplements)? No changes in medications. Patient reports takin an antihistamine and creatine. Any medical problems that run in your family? Dad reports overweight, high blood pressure and depression. Whatever is listed in his chart. Does your heart every race or skip beats during exercise? No palpitations, Have you had headaches with exercise? No Do you get lightheaded or feel shorter of breath than expected during exercise? No Do you get tired or short of breath more quickly than your friends during exercise? No Any chest pain upon exertion? No chest pain, discomfort or pressure. No pain/pressure/dizziness with exertion or getting angry. Have you ever had a seizure? Dad reports no seizures. Any problems with your eyes or vision? (seeing sports in your visual field) – Reports no problems with eyes. No troubles with vision. No distortions or loss of central vision. Do you worry about your weight? Are you trying to or has anyone recommended that you gain or lose weight? Reports no diets in the last year. Does not keep track of how much he drinks. Patient reports that he drank Gatorade when the coaches gave him some. He did not drink during normal water breaks today. Does not feel dry, dehydrated, or drained of moisture. +Exercising Vigorously. Summer football work started a month ago. He reports starting lifting weights and running, sprints and wearing gear. Are you on a special diet or do you avoid certain types of foods? Any recent infections? No recent acute or chronic infections. Reports overall health is pretty good. No problems with fatigue, difficulty sleeping, unintentional weight loss or gain, fevers, or night sweats.
HPI: Patient is an 18 year-old Caucasian male high school senior who reports to the clinic with his father. Patient states, "I passed out at football practice. My trainer thinks it's because of the heat index being 100 and that I didn't drink enough." He states that incident occurred about an hour ago and prior, he was running 2-mile laps and noticed his legs were hurting. Patient reports loss of hearing and vision changes. Episode was witnessed by his trainer who reports that she noticed him stop, stumble a bit, and then went down. Patient lost consciousness for a few seconds. Patient does not report any preceding symptoms. He did not remember falling. Muscles have been sore throughout the week. Patient reports a headache that began an hour into his practice. Denies any head trauma. Patient has never passed out before. No past injuries. Vigorously exercising with his summer football that involves lifting weights, running, sprints, and wearing gear. Patient reports recently starting two-a-day practices. General: Patient is an overall healthy 18 year-old male who plays football. Patient reports excessive sweating today. No recent acute or chronic infections reported. HEENT/Neck: Patient reports loss of hearing and vision changes, prior to passing out. He describes the vision changes just black and white, without any color, then it coned down to a pinhole. Reports no problems with eyes. No trouble with vision. No distortions or loss of central vision. Cardiovascular: Denies any palpitations. No chest pain, discomfort, or pressure. No pain, pressure, or dizziness with exertion or getting angry. Patient denies feeling lightheaded during exercise. Respiratory: No shortness of breath before fainting. Patient denies feeling short of breath during exercise. Gastrointestinal: No diets in the last year. Does not keep track of how much he drinks. Patient did not drink during normal water breaks at football practice today, and remembers drinking a Gatorade that one of the coaches gave him. Does not feel dry, dehydrated, or drained of moisture. Gastrourinary: Deferred. Musculoskeletal: Reports sore muscles. Exercising vigorously. Neurologic: Patient's father reports no seizures. Patient reports a headache that started about 1 hour into his football practice (roughly 6 hours ago). Reports 8/10 pain at lunchtime and 3/10 pain now. Patient normally does not suffer from headaches. Denies any trauma. Integumentary: Deferred. Psychiatric: Deferred. Endocrine: Deferred. Hematologic: Deferred. Allergic/Immunologic: Patient reports seasonal allergies to grass and mold, which cause him to sneeze and rhinitis, which is worse in the fall. Past Medical History: PMH: Allergic Rhinitis, Elevated BMI Hospitalizations/Surgeries: No medical, surgical, or dental procedures reported. Preventative Health: Patient reports sleeping 6-8 hours per night. Medications: Patient denies any prescription medications. He reports taking over-the-counter antihistamines and supplement of creatine.
Allergies: Patient denies any allergies to medications. He reports seasonal allergies to grass and mold, which cause him to sneeze and rhinitis that is worse in the fall. Social History: Patient drinks alcohol at parties and endorses that sometimes he gets drunk, but it's not a regular thing. His drinking has never caused any problems. Patient states it is a way to let loose from game stress on weekends with his football buddies. Patient admits to smoking for about 1-2 years. He smokes weed occasionally on the weekends and vapes 1 cartridge a week. Family History: Patient's father reports Obesity, Hypertension, Depression, and whatever else is previously listed in his chart. Previous Records indicate: Natural Siblings: Environmental Allergies Natural Mother: Obesity, Depression Natural Father: Environmental Allergies, Hypertension Maternal Grandfather: COPD, Diabetes Mellitus Type II, Hypertension Maternal Grandmother: Alzheimer's Disease Paternal Grandfather: Unknown Paternal Grandmother: Unknown Before passing out, did you feel dizzy, cold, clammy, weak, stressed, anxious or nauseous? Dehydration, overworking, Exercising or woking too hard in the heat, skipping multiple meals, standing too fast, hyperventilating, and using drugs/alcohol can chouse a person to pass out Any neurologic disorder (ex: seizures, drop in blood pressure, diabetes, taking certain medications like diuretics, ca channel blockers, narcotics, and medications for allergies continaing antihistamines and ACE inhibitors) Abnormal History or Complaints Key Findings List Physical Examination: Patient’s clothes are drenched in sweat. His skin is cool and clammy to touch. Appears slightly pale. No bruising or lacerations noted. Normal skin turgor. Left & Right Pupils are normal reactive. Visual Acuity with Snellen pocket card: Right Eye 20/20 Left Eye 20/ Ears: Normal appearing external structures. No deformities or edema. No discharged noted. Tympanic membranes – bilateral light reflex, no hemotypanum. Hearing tested – no hearing deficits. Normal Weber and Rinne tests. Respiratory: Bilateral lung fields clear upon auscultation. Musculoskeletal: Normal bulk and tone. No rigidity. Strength is 5/5 bilaterally. Neurological: MMSE: 3/3 registration and recall. Attention intact. Names 2/2 objects accurately. Able to follow multistep command. Spatial and executive function intact on drawing task. Score 30/30.
Balance test normal. No dysmetria (able to perform smooth, coordinated, upper extremity movements). Normal point-to-point test legs (heel down shin). ROM is normal and equal bilaterally. HPI: Onset: Location/Radiation: Duration: Character: Aggravating Factors: Relieving Factors: Timing: Severity: ROS (based on questions you asked)
Order Tests (for top 2 diagnoses) Review Results Select Final Diagnosis Management Plan Template Primary Diagnosis with ICD-10 Code:
References Chhabra, L., Goyal, A., & Beham, M. D. (2022). Wolff Parkinson white syndrome. Retrieved from https: //www.ncbi.nlm.nih.gov/books/NBK554437/. Kim, M. J., & Farrell, J. (2022). Orthostatic hypotension: A practical approach. American Family Physician, 105 (1), 39-49. Reneker, J. C., Cheruvu, V., Yang, J., Cook, C. E., James, M. A., Moughiman, M. C., & Congeni, J. A. (2015). Differential diagnosis of dizziness after a sports-related concussion based on descriptors and t riggers: an observational study. Injury epidemiology , 2 (1), 22. https://doi.org/10.1186/s40621015- 0055 - 2. Rusner, L. A., Gauer, R. L., & Houser, A. (2017). Syncope: Evaluation and differential diagnosis. Am Fam Physician, 95 (5), 303-312. Retrieved from www.pubmed.ncbi.nlm.gov/28290647/. Stanton, M., & Freeman, A. M. (2022). Vertigo. Retrieved from https://www.ncbi.nlm.nih.gov/books /NBK482356/.
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