Patient Presentation

1
Patient Presentation

• Ahmed Khan
• October 29, 2004

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Chief Complaint

• The patient is a 52-year-old married white male
  who came in because he was taken to the
  Emergency Room after fainting two days earlier
  and wanted to know what happened.

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Present History

• Complained of increased headaches for last 2-4
  weeks
• Looked pale, according to a coworker
• Passed out
• Was in ER for one day

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Present History
5
Past History/Past X-rays

• Accident when patient was 18 years old
• Broken right forearm
• Broken clavicle
• Cranial damage

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Medications/Allergies

• No medications
• No allergies

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Family/Social History

• Mother and uncle both have hyperglycemia
• Married Caucasian car dealer
• Lived in Elizabeth City entire life
• Has extended family nearby, with good relations
• Strong Christian background

8
Physical Exam

• Head, ears, eyes, nose, throat were unremarkable
• Lungs clear, heart was unremarkable
• Muscle strength was intact (all 5)
• Cranial Nerves II-XII intact

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Vitals

• Height 5 7
• Weight 165 lbs.
• BP 128/70
• Pulse 76
• Respiration 17
• The patient appeared to be a healthy male who
  appeared his age (52).

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Labs

• Only remarkable was finding was that the
  patient had a slightly elevated blood glucose
  level of 110.

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Assessment

• Syncopal episode (fainting)
• Slightly elevated white blood cell count
• Elevated blood glucose levels

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Treatment Plan

• Refer to neurologist for further evaluation
• Continue to monitor blood glucose levels

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