S:

JM is an 87 yo male with PMH significant for leukemia with chief complaint of “weakness and lightheadedness.” Patient states his oncologist sent him for a blood transfusion. Bloodwork done on 1/10/2019 shows H/H of 6.8/21.6. Last transfusion was 3 weeks ago. Admits weakness and lightheadedness. Denies fever, chills, shortness of breath, chest pain, palpitations, headache, cold intolerance, relation to transitioning from sitting or lying to standing.

PMH: Leukemia, Colon Cancer, Hyperlipidemia, Hypothyroidism, HTN, Cerebrovascular Disease, BPH

PSH: Partial Colectomy (2001), Cerebral Aneurysm Repair

Allergies: NKDA

Medications: Losartan-HCTZ 100mg/12.5mg PO qd, Levothyroxine 25mcg PO qd, Atorvastatin (Lipitor) 80mg PO qd, Tamsulosin (Flomax) 0.4mg PO qd

FHx: Unknown

SHx: Non-contributory

O:

T 37C | BP 114/63mmHg | P 85 BPM, regular | RR 16 breaths/min, unlabored | O2 97% RA

H 71in | W 185 lb. | BMI 25.8

Gen: Average-build male. Neatly groomed. Looks his stated age. Alert and cooperative and in no apparent distress.

HEENT: Symmetrical OU. No strabismus, exophthalmos, or ptosis. Sclera are white and nonicteric. Conjunctiva and cornea clear. No conjunctival pallor.

CV: RRR. S1 and S2 are normal. No S3, S4, murmurs, splitting of heart sounds, friction rubs.

Pulm: Clear to auscultation and percussion bilaterally. Chest expansion symmetrical. No wheezing, rhonchi, rales, dullness.

A:

87 yo male with PMH significant for leukemia with symptomatic anemia.

Differential Diagnosis:

1. Symptomatic Anemia
2. Orthostatic Hypotension
3. Hypoglycemia
4. Medication Side Effect

P:

Labs:

• CBC, BMP
• T/S
• Finger stick Glucose

Anemia

• Start 1L Normal Saline IV
• Pending H/H, T/S, plan for pRBC transfusion

Leukemia, Colon Cancer:

• follow up with Oncologist

Hyperlipidemia:

• Atorvastatin (Lipitor) 80mg PO qd

Hypothyroidism:

• Levothyroxine 25mcg PO qd

Hypertension:

• Losartan-HCTZ 100mg/12.5mg PO qd

BPH

• Tamsulosin (Flomax) 0.4mg PO qd

 

/s/ Daniel DeMarco, PA-S

Physician Assistant Student

 

Initial DDx Based on CC:                                              Adjusted DDx After H&P:

Symptomatic Anemia                                                 Symptomatic Anemia

Orthostatic Hypotension                                            Orthostatic Hypotension

Hypoglycemia                                                             Hypoglycemia

Medication Side Effect                                               Medication Side Effect

Stroke or TIA

Vertigo

Panic Attack

Carbon Monoxide Poisoning

Aortic Stenosis