EVAN TYSON INHUMAN 2026, Exams of Nursing

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Evan Tyson 65 y/o 6'0" (183 cm) 216.0 Ib (98.2 kg) Reason for encounter Tired and peeing at night Review Submitted on 08/14/2021 13:16:21 Case authored by: Steven Durning, MD, PhD, FACP. Reason for Encounter Start with open-ended patient-centric questions, @ Asked X Not asked Graded Approach Question cc sx cc sx Assoc Sx Assoc Sx Assoc Sx Assoc Sx Assoc Sx Etiology Etiology Is the amount you urinate more or less than usual? How can I help you today? Do you have pain/discomtort when you urinate? Do you have difficulty getting or keeping an erection (erectile dysfunction)? Do you have any other symptoms or concerns we should discuss? Any tingling or numbness in your feet? Have you gained or lost weight unintentionally, despite normal appetite and exercise? How much waterifluids do you drink in a day? How is your appetite? Any recent change? Response I's got to be more since I have to go so often. I've been unusually tired for the last few weeks - well, maybe longer, like a few months. I'm not sure. | think itis because I'm not getting any sleep because | have to get up and pee so much during the night. My wife has been telling me | needed to come in and get it evaluated. She thought | might have something wrong with my kidneys. No, just a whole lot of urinating. Both... embarrassing to have to admit that. My wife said | should also tell you my vision sometimes gets a bit blurry. Also, this is kind of embarrassing, but I've had some recent problems with sex. You know, "getting it up". I notice I have like a pins-and- needles sensation in my feet more often. You know, like my feet “went to sleep". On the soles mostly. Well, when I retired, | just sat around too much and gained quite a bit of weight, tipped the scales at about 220. But, over the last couple of weeks, I've lost 4-5 pounds without really trying. I's, weird... the funny thing is that | have been eating a lot and not sure how that happened. Maybe itis all water weight I've been losing peeing. What do you think? About 4 liters a day. It's definitely increased. Information Obtained Clinic Notes EHR Do you have problems with dizziness, fainting, spinning room, seizures, weakness, numbness, tingling, or tremor? Do you have any problems with an itchy scalp, skin changes, moles, thinning hair, or brittle nails? Do you have any problems with nervousness, depression, lack of interest, sadness, memory loss, or mood changes, or ever hear voices or see things that you know are not there? Do you have any problems with headaches that don't go away with aspirin or Tylenol (acetaminophen), double or blurred vision, difficulty with night vision, problems hearing, ear pain, sinus problems, chronic sore throats, or difficulty swallowing? Do you experience chest pain discomfort or pressure; pain/pressure/dizziness with exertion or getting angry; palpitations; decreased exercise tolerance; or blue/cold fingers and toes? Do you experience shortness of breath, wheezing, difficulty catching your breath, chronic cough, or sputum production? Do you have problems with nausea, vomiting, constipation, diarrhea, coffee grounds in your vomit, dark tarry stool, bright red blood in your bowel movements, early satiety, or bloating? | [__ show Dialogue ''m just lightheaded when | stand up fast. But | wouldn't call that dizzy at all. 'd say I'm tired more than weak. Now what was it you asked again? haven't noticed any of that. Hearing voices?!7! Are you serious? I may not be getting sleep, but | don't think I'm going nuts. Well, did | tell you about the blurred vision? That's all there. No. Well I'm tired so don't want to exercise much. Is that what you want to know? No. That sounds nasty. | don't have any of that. Hx Notes Proceed Exams Feedback @ Performed Correctly ‘+ auscultate abdomen © You performed the simulation correctly. auscultate heart © You performed the simulation correctly. © Your documentation was correct. blood pressure genitourinary male exam Erectile abnormalities can result from low testosterone levels which might be seen in testicular volume. orthostatic blood pressure (BP) palpate abdomen Palpation of the abdomen is to evaluate for: © masses © organomegaly (liver and spleen) © aorta diameter pulse test visual acuity Visual acuity is important in any person that presents with a complaint of a visual problem. ual inspection abdomen ‘Abdominal inspection is looking for abdominal hernias and other vascular markers. visual inspection extremities ‘comprehensive visual inspection of the lower-extremities should address all of the following: © Signs of impaired peripheral perfusion and/or oxygenation, breakdownJulceration \cluding secondary signs of poor healing and skin © Signs of fluid overload © Signs of impaired venous return © Musculoskeletal pathology: muscle wasting, joint swelling or inflammation © Other skin, nail, and hair changes Several historical factors should prompt visual inspection of this patient's lower extremities: © Altered fluid status © Symptoms suggestive of diabetes mellitus Organize Findings Your Findings Case Findings Write Key Finding MSAP Relation Key Finding MSAP Problem Relat Statement, Nocturia MSAP ss scar Era Fatigue RELATED ey ipsi RELATED Problem Erectile Disfunction RELATED Polydipsia Categories iT ef AIaRASEEED TaD, Numbness and paresthesias of feet. RELATED Select Blurred vision: decreased visual acuity RELATED Differential per exam Diagnosis ‘Sexual (erectile) dysfunction RELATED Hebe | Diminished vibratory sensation to level RELATED {isIE of knees; diminished light-touch Diagnosis sensation in the feet — Increasing fatigue x weeks tomonths — RELATED ests Central obesity: waist circumference RELATED MI=29.3 Elevated blood pressure RELATED Unintentional weight loss 4-5ibs RELATED Increased appetite UNKNOWN Feedback The medical key findings list you have compiled should be a list that includes everything that is out of the ordinary about this patient, even when it is not a "problem' in the true sense of the word. In this case, the most significant active problem (MSAP) may be difficult to determine as many are of concern, but polyuria could result in severe dehydration and cardiovascular collapse if the patient’s access to water is limited, thus, this was chosen as the MASP. Note that the MSAP from the physician's perspective may not be the chief complaint that brought the patient to seek medical attention, The cause of polyuria is short and includes solute diuresis or osmotic diuresis and polydipsia. Two common solutes that can cause this polyuria are glucose and urea. What other items on the key findings list would either put the patient at increased risk of having hyperglycemia or elevated blood urea levels? What would the symptoms be for each? What hormone is important for water maintenance? Does your key findings list contain any signs or symptoms suggestive of an absence or resistance to this hormone? Where does this hormone act? Isn't fatigue a common symptom in renal disease? What about the blurred vision and erectile dysfunction? How might these symptoms be linked to the polyuria? Finally, how does his fatigue, unintentional weight loss and neurologic findings fit into this case? Can you identify a single unifying diagnosis or will it require two or more different diagnoses? Is the weight loss due to water loss or real body fat and muscle loss? Proceed Select Problem Categories Select Differential Diagnosis Rank Differential Diagnosis Select Tests Case Problem Statement Evan Tyson is a 65-year-old retired military male who complains of fatigue, thirst (4 liters water/day) and polyuria/nocturia, blurred vision, peripheral neuropathy and erectile dysfunction of several weeks’ to months' duration. He reports an associated increase in appetite, with recent unintentional weight loss. Physical exam finds elevated blood pressure, central obesity (waist 48”), borderline orthostatic BP and bilateral diminished sensation to vibration and light touch to the level of his knees. Past medical history is non-contributory. FH significant for sister with obesity and type 2 diabetes. Feedback Diagnosis Diagnosis: New-onset type 2 diabetes mellitus Discussion: Mr. Tyson's presenting symptoms of increased fatigue; thirst, urination, and appetite are consistent with new-onset type 2 diabetes mellitus and the resulting hyperglycemic osmotic diuresis. His associated symptoms of visual disturbance, numbness and paresthesias of the feet, and sexual dysfunction are secondary effects of uncontrolled glucose levels that have probably been going on for years with high post-prandial blood sugars. The laboratory finding of elevated HbAtc (9.1%) indicates the average severity of his hyperglycemic state. His blood sugar of 230 mg/dL. shows he is doing a pretty good job of staying hydrated despite the osmotic diuresis. Proceed Case Plan Assessment / Plan - New onset type 2 Diabetes Mellitus ‘* Comprehensive diabetic counseling on weight reduction/exercise + Nutritional assessment and education © How insulin works © What foods are high in: carbohydrates versus proteins versus fats © Importance of diet balance/calorie counting/carbohydrate moderation © Glycemic index and "free foods" those that do not need insulin ‘* Baseline evaluations: Vascular, ophthalmological, podiatric * Urological consultation regarding sexual dysfunction * Longitudinal clinical and laboratory monitoring © FSG monitoring © HgAtc © Renal function © Fasting Lipids © Weight Proceed