1. List pertinent positives and negatives 2.

1. List pertinent positives and negatives 2. What additional information would you ask? 3. Name three potential differential diagnoses 4. What would be your primary diagnosis and plan of care according to national guidelines? C.C. “I feel dizzy.” HPI: 68 y.o. M presented to HU Clinic reporting dizziness started about 10 hours ago. First noticed the dizziness when he got up to use the bathroom in the early this morning. Finds it to be constant and has mild headache. He does not associate the situation with any aggravating factor. But did noticed increase thirst and urination starting this morning. He denies any relieving factors. He has not tried any over-the-counter medication to manage the dizziness. His glucose was 128 this afternoon, he does not check his glucose in the morning. Past medical history: Type 2 DM (2012). Shingles and pneumococcal vaccine (2018). No history of trauma, surgery, or significant hospital admission. Allergies: No known allergies Medications: Metformin 500mg BID. Social history: Hispanic, lives with wife and a father of two children. He is a retired from the military. Christian faith. He denies tobacco, alcohol, and illicit drug use. Family history: Mother has dementia and hypertensive. Father (deceased) had diabetes. Maternal grandmother had hypertension. Maternal grandfather was in good health and died from old age. Paternal grandmother was without chronic illnesses. Paternal grandfather suffered diabetes. He does not have any siblings. Review of system General – reports dizziness; denies fever, chills or fatigue Skin – denies rash and skin ulcer HEENT -denies hearing and vision loss, notes mild frontal headache Neck – denies swelling and stiffness Cardiovascular – denies chest pain,/tightness palpitations, heart racing Pulmonary – denies shortness of breath, cough Gastrointestinal – denies abdominal pain, nausea, vomiting, and diarrhea. No change in appetite or weight loss. Genitourinary – Reports increase urination but denies burning or blood. Peripheral vascular – denies discoloration and edema Musculoskeletal – denies muscle and joint ache Neurological – denies confusion, memory loss, numbness or tingling. Has mild frontal headache rating 2/10. Dizziness is constant, started when he woke up in the middle of the night to use the bathroom. Denies lightheadedness or feeling of faintness. Denies unsteadiness or room spinning. Psychological – denies anxiety, depression and confusion Endocrine: Increase urination and thirst. Denies weight loss or weight gain. Hematologic: Denies bruising or bleeding easily. Objective Data Vital signs:. T- 98.6 F, HR- 89 RR- 16, BP – 160/97 mmHg, pain 2/10 Pulse ox – 95%, Wt.: 187 lbs. Ht 68 in, BMI 28.43 General appearance: No acute distress, well-nourished and cleanly kept. HEENT: Normocephalic, face symmetrical. PERRLA, Conjunctiva pink, sclera white. Cornea and lens are clear. Normal fundus exam. Auditory canal intact and clear, TM appears grey and intact, no effusion, bulging or erythema noted. Bony landmarks and light reflex visualized bilaterally. Hearing intact. Oral mucosa moist without ulcerations or lesions. +1 tonsils, no erythema or exudates present. Uvula midline. Good dentition. Neck: Non-palpable, non-tender lymph nodes. Thyroid gland without enlargement or nodules. CV: Regular rate, harsh crescendo-decrescendo systolic murmur noted best in the right upper sternal border radiates to carotid arteries. Lungs: Bilaterally clear to auscultation, no adventitious sounds. No clubbing noted. Abdomen: Bowel sounds present in all four quadrants, abdomen is soft and non-tender, no guarding, no rebound, no enlargement, or organomegaly noted. Central obesity noted Genitourinary: No lesions, ulcerations or discharge PV: B/L, equal +2 bounding radial, femoral and pedal pulses. Capillary refill less than 3 seconds. No swelling, erythema or ulcerations on exam. MSK: Normal gait, good muscle tone, active and passive ROM within normal ranges. Integumentary: No petechiae, ulcers, jaundice, or lesions Neuro: Alert and oriented to person, place, date and situation. Appropriate conversation. Strength 5/5 throughout. Cerebellar Rapid alternating movements (RAMs), point-to-point movements intact. Pinprick, light touch, position sense, vibration, and 2-point discrimination intact. Romberg negative. Reflexes: 2+ (brisk) deep tendon reflexes of biceps, triceps, brachioradialis, patellar, Achilles, and plantar. Psychiatric: Behavior appropriate for the age. Thoughts are coherent Neurological: Awake, alert, oriented, cooperative. Speech is clear. Oriented to person, place, and time.

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