Evan Tyson Ihuman Case Peeing at Night and Fatigue, Exams of Integrated Case Studies

Download Evan Tyson Ihuman Case Peeing at Night and Fatigue and more Exams Integrated Case Studies in PDF only on Docsity! Evan Tyson Ihuman Case Peeing at Night and Fatigue 65 y/o 6' 0" (183 cm) 216.0 1b (98.2 kg) Reason for encounter Peeing at Night and Fatigue Tired and peeing at night Reason for Encounter Start with open-ended patient-centric questions. O Asked X Not asked Graded Approach Question Response Information Obtained Clinic Notes cc SX Is the amount you urinate more or less than usual? It's got to be more since I have to go so often. cc SX How can I help you today? lye been unusually tired for the last few weeks well, maybe longer, like a few months. I'm not sure. I think it is because I'm not getting any sleep because I have to get up and pee so much during the night. My wife has been telling me I needed to come in and get it evaluated. She thought I might have something wrong with my kidneys. X Assoc sx Do you have pain/discomfort when you urinate? No, just a whole lot of urinating. Assoc sx Do you have difficulty getting or keeping an erection (erectile dysfunction)? Both... embarrassing to have to admit that. Assoc sx Do you have any other symptoms or concerns we should discuss? My wife said I 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". X Assoc sx Any tingling or numbness in your feet? I notice I have like a pins- andneedles sensation in my feet more often. You know, like my feet "went to sleep". On the soles mostly. Asked X Not asked Review of Systems (ROS) Select the major body systems that have not been touched on during the interview process for the HPI. Asked X Not asked History Physical Exam Assessment Test Results Diagnosis Plan Summary x PMH Any new or recent change in medications? No. I don't have any regular prescribed meds. x PMH Are you taking any over-thecounter or herbal medications? Just multivitamins and a few supplements. Nothing like steroids, you know; just some additional vitamins. x PMH Do you have any allergies? Not that I know of. History Physical Exam Assessment Test Results Diagnosis Plan Summary Graded Question Response Information Obtained Clinic Notes X Have you noticed any bruising, bleeding gums, nose bleeds, or other sites of increased bleeding? Uh...no. Do you have problems with dizziness, fainting, spinning room, seizures, weakness, numbness, tingling, or tremor? I'm just lightheaded when I stand up Stu fast. But I wouldnt call that dizzy at all. I'd say I'm tired more than weak. Now what was it you asked again? via.com - The Marketplac X Do you have any problems with an itchy scalp, skin changes, moles, thinning hair, or brittle nails? I havent noticed any of that. 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? Hearing voices?!?! Are you serious? I may not be getting sleep, but I dont think I'm going nuts. X Do you have any problems with headaches that dont 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? Well, did I tell you about the blurred vision? That's all there. History Physical Exam Assessment Test Results Diagnosis Plan Summary • auscultate lungs o You did not perform any simulation. • You did not document anything for left lung. • You did not document anything for right lung. • inspect eyes In a complaint of a visual problem, start with inspection looking for signs of edema, redness or tenderness that would suggest an infectious process. • inspect hair color, distribution, thickness Erectile difficulties can be due to hormonal, vascular or psychologic problems. Therefore, evaluating a patient for changes in male hair distribution and thickness (indicative of testosterone stimulation) can provide evidence to increase or decrease one's suspicion for a hormone disturbance. • look in eyes with ophthalmoscope There are many causes of blurred vision, see list below, so it is important to do a fundoscopic exam to directly exam the retina and optic nerve for serious treatable problems. Acute maculopathy Optic neuritis Multiple sclerosis Papilledema Chiasmal problems Lens changes Dirty contacts Hyperglycemia Psychogenic • measure girth Abdominal obesity is an independent risk factor for type 2 diabetes mellitus as well as being at increased risk for heart disease, hypertension, dyslipidemia and nonalcoholic fatty liver disease. Prevailing guidelines define abdominal obesity in terms of waist circumference: • Women: 35" (88 cm) or greater o Men: 40" (102 cm) or greater • monofilament test The monofiliment test is a simple way to quantify the degree of sensory deficits as a specific pressure is needed to result in the bending of a filament. • palpate neck o The thyroid should be evaluated for overall size, consistency, and palpable irregularities (nodules). • reflexes - deep tendon An extremity neurologic exam is important in any patient that presents with peripheral extremity complaints. • You did not perform any simulation. • sensory tests (light touch, pain, position, temperature, vibration) Sensory testing includes: light touch, pain, position, temperature and vibration. The type of test is documented as well as the extent (location) of any abnormal findings. It is also important to determine if a deficit is bilateral versus unilateral. History Physical Exam Assessment Test Results Diagnosis Plan Summary History Physical Exam Assessment Test Results Diagnosis Plan Summary Organize Key Findings Your Findings Case Findings Feedback The medical key findings list you have compiled should this patient, even when it is not a "problem" in the true problem (MSAP) may be difficult to determine as many and cardiovascular collapse if the patient's access to MSAP from the physician's perspective may not be the attention. The cause of polyuria is short and includes solute diuresis can cause this polyuria are glucose and urea. What other increased risk of having hyperglycemia or elevated blood Write Problem Statement Select Problem Categorie Select Differential Diagnosis Rank Differential Diagnosis Select Tests Key Finding MSAP Relation Nocturia MSAP Fatigue RELATED Erectile Disfunction RELATED Blurry Vision RELATED Key Finding MSAP Relation Polyuria MSAP Polydipsia RELATED Numbness and paresthesias of feet RELATED Blurred vision: decreased visual acuity per exam RELATED Sexual (erectile) dysfunction RELATED Diminished vibratory sensation to level of knees; diminished light- touch sensation in the feet RELATED Increasing fatigue x weeks to months RELATED Organize Key Findings Comparison to Case Correct X Missed C Incorrect Write Problem Statement Select Problem Categories Select Differential Diagnosis Rank Differential Diagnosis Select Tests Choice Yours Graded Cardiovascular Endocrine Gastrointestinal Integumentary Musculoskeletal Neurological x 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 HbA1c (9.1%) indicates History Physical Exam Assessment Test Results Diagnosis Plan Summary Feedback Endocrine • The patient presents with a constellation of symptoms suggestive of an endocrinopathy: polyuria, polydipsia, and polyphagia Renal • Whether as a primary or secondary pathophysiologic process, the patient is producing an excessive volume of urine. Neurological • While this patient has neurological symptoms (visual disturbance; peripheral numbness and tingling), his presentation is likely not that of a primary neurological condition. EHR Proceed History Physical Exam Assessment Test Results pj_agnosis Plan Summary Genitourinary/Renal x Respiratory Hematologic Lymphatic Immune Psychologic Sexual/Reproductive 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. EHR Proceed