Week #7(Class 6512) Comprehensive Ihuman Case Study 18-Year-Old Patient
Reason For Encounter: Passed Out
Patient Demographics:
• Age: 18 years old
• Height: 6' 0" (183 cm)
• Weight: 220.0 lb (100.9 kg)
Reason for E
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Week #7(Class 6512) Comprehensive Ihuman Case Study 18-Year-Old Patient
Reason For Encounter: Passed Out
Patient Demographics:
• Age: 18 years old
• Height: 6' 0" (183 cm)
• Weight: 220.0 lb (100.9 kg)
Reason for Encounter: Passed out
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Case Study Report
Week #7 i-Human Case Study Class 6512
18-Year-Old Patient – Reason for encounter: Passed out Location: Unspecified
Title Page
Case Study Title:
Comprehensive Assessment of an 18-Year-Old Patient Presenting with Syncope
Author:[Your Name]
Date:[Submission Date]
Table of Contents
1. Introduction
2. Chief Complaint (CC)
3. History of Present Illness (HPI) – Includes HPI Questions and Answers
4. Past Medical, Social, and Family History
5. Review of Systems (ROS)
6. Physical Examination (PE)
7. Differential Diagnoses (DDX)
8. Diagnostic Workup
9. Final Diagnosis
10. Treatment Plan
11. Management Strategies
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12. Follow-Up and Prognosis
13. Discussion
14. References
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1. Introduction
Syncope in young adults is common yet multifaceted in its etiology,requiring thorough evaluation to rule out cardiac, neurological, or situational causes. This report focuses on evaluating the case of an18-year-old patient who presented after a syncopal episode, aimingfor accurate diagnosis and prompt intervention.
2. Chief Complaint (CC)
The patient states: “I passed out.”
3. History of Present Illness (HPI)
Patient’s Statement:
“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. We have a big game tomorrow so I just need to make sure I can play.”
Senior in high school
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Detailed HPI Questions and Answers
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 Inoticed 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 havebeen 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 me 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 outfor 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.
+ Headache that started an hour into morning practice ( 6 hours ago.) Denies any trauma. 8/10 pain atlunchtime and now 3/10 pain. No come/go. Usually does not suffer from headaches.
Football is the only sport he plays now. Patient used to play lacrosse, but quit 2 years ago. He startedtwo practices a day this week.
Reports sleeping 6-8 hours per night
Do you have any ongoing medical issues? Only allergies and the things that were told to patient at lastvisit.
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 ismuch worse in the fall.
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Any past injuries? (concussions, sprains, or broken bones)
Are you taking any medications (prescription, over the counter, dietary supplements)? No changes inmedications. Patient reports takin an antihistamine and creatine.
Any medical problems that run in your family? Dad reports overweight, high blood pressure anddepression. Whatever is listed in his chart.
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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 withexertion 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 witheyes. 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 lastyear. 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 weightsand 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 weightloss or gain, fevers, or night sweats.
+ Drinks alcohol at parties. Sometimes he gets drunk, but not every day or anything. Never caused anyproblems. He reports that it is a way to let loose from game stress on weekends with his football buddies.
+Smoking weed occasionally on the weekends.
+Vaping. 1 cartridge a week
+Reports smoking for a year to two
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Chief Complaint: “Passed out at football practice”
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, andthen 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 through
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