Full Pаtient Histоry (PLO 1) HPI: Mr. Reynаud is а 23 y/о M presenting tо urgent care for evaluation of the sense that he feels like he is “dying” at times. He reports this started approximately 2 months ago. The can reports he can specifically recall the first such episode. Pt states he feels the following sensations during episodes; he feels short of breath, pounding and racing heart sensation, nauseousness, and tingling throughout his extremities. Pt states that the episodes last approximately 3-5 minutes and don’t seem to occur with any specific event. These mostly occur at rest or at work and have not occurred during exercise or exertion. He states the symptoms completely resolve after 5-15 minutes. Since first starting, he has now had 4-5 episodes and for the last 5-6 weeks reports he is scared he is going to have more. He states he doesn’t want to die. He reports going to the ER last week for these symptoms and states he underwent a “heart evaluation and testing” that he was told was “fine” and that all tests were negative and was sent home to follow up with his family doctor as needed. He admits to receiving an unknown medication during his visit which made him feel better. He was sent home without any new medications or prescriptions. He notes the episodes have increased in frequency since his side hustle workload has increased on top of his restaurant job. He admits to feeling under pressure to find a “real job” by his family and admits to using his marijuana vape to help calm him down after work a few times per week. He often speaks with his sister for social support. Patient denies SI/HI, leg swelling, syncope, headaches, changes in vision, chest pain, recent injuries, weakness or numbness anywhere. Between episodes, he denies having any unusual symptoms. Medications: Melatonin 10mg PO QHS Allergies: NKDA Past Medical History: Chronic conditions: Primary insomnia (diagnosed by PCP 6 months ago) No other reported chronic conditions Pt denies hx of DVT/PE Surgeries: R hand (ring finger) fracture repair with pin placement (2009). No other recent surgeries. Immunizations: Pt believes he is up to date on his required vaccines/immunizations. Family History: Father: alive, 56 years old. Known hx of high cholesterol Mother: alive, 55 years old. Known hx of asthma and depression Sister: alive, age 20, Known hx of anxiety, otherwise healthy Brother: alive, age 18, Known hx of traumatic brain injury after being hit by a car at age 10 Social History: Tobacco/Vape: Frequent daily use of electronic vape use (tobacco/nicotine), typically for stress relief. Pt states he does this at last 2-3 times per hour. Caffeine Use: Pt does not use caffeinated products. Alcohol: Pt denies alcohol use on a routine basis. Illicit drugs: Pt reports using a vape that contains THC/marijuana. Pt states he does this 2-3 times per week, usually after work or a busy day. Marital/Sexual: Pt is single. Reports being sexually active with two female partners over the last year. States he uses condoms when sexually active. Living situation: Lives with his parents in La Jolla after graduating college to save up some money to move out on his own. Job: Works at a busy French cuisine restaurant in La Jolla. Pt states the job is demanding and stressful to ensure no mistakes are made. Reports he was almost fired last week after making a mistake with a large table order. Pt also works as a social media/lifestyle photographer on the side, which he enjoys. Hobbies: Surfing, diving, photography, prior cross-country runner in high school. Diet: Normal diet. No specific restrictions. Pt admits to eating staff meals at work when he can since they are provided free. Religion: Agnostic Sleep: Averages 3-5 hours of sleep per night ROS: Constitutional: Denies fever, chills, night sweats, unintentional weight loss or weight gain recently. Reports normal appetite. Skin: Denies hair loss, nail pitting, rashes, lesions, or skin discoloration. HEENT: Denies rhinitis, sore throat, congestion, ear pain or discharge, eye pain or change in vision, headache. Denies hearing changes, tinnitus, or nasal discharge. No lymph node swelling reported. CV/PV: See HPI. Denies chest pain or tightness, swelling or edema of lower extremities. No syncope or pre-syncope reported. Pulmonary: Admits to episodes of brief SOB as noted in HPI. Denies coughing, wheezing, hemoptysis, stridor, dyspnea, orthopnea, or pain with inspiration. GI: Admits to occasional nausea during episodes noted in HPI. Denies constipation, diarrhea, abdominal pain or distention, or vomiting. GU: Denies dysuria, increased (or decreased) urinary frequency, urgency, or hematuria. Denies urinary incontinence. No unusual vaginal bleeding or discharge. MSK: Denies trauma, muscle weakness, joint swelling or joint pain, difficulty moving any joints, arthralgias or myalgias. Neuro: Admits to episodes of tingling in all four extremities as noted in the HPI. Denies headache, dizziness or lightheadedness, dysarthria, slurred speech, or weakness. Denies seizures, tremors, or confusion. No other weakness observed. Psych: See HPI. Admits to feeling anxious about his work situation, which waxes and wanes depending on the week. Denies depression, fear of leaving his home, racing thoughts, suicidal ideation, homicidal ideation or hallucinations. Endocrine: Denies heat or cold intolerance, polyuria, polydipsia, or polyphagia. Heme/Lymph: Denies any recent or remote easy bruising or bleeding. Critical Review of the Patient History: (A.) (A.) Based on the provided patient history and ROS above, please identify your top TWO most likely differential diagnoses. [PLO 2] (B.) Based on your top two differentials, please identify 10 aspects of the patient’s history and/or ROS above that specifically help to support your differentials. Please provide brief rationale for each item provided and identify which differential is associated with each answer. [PLO 1]
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