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BODHI BROWN
, lOMoAR cPSD| 24448587
An 18 year old male patient with a history of active smoking and occasional
alcohol
binging came in with the chief complaint off passing out during football practice he
fell to the ground and regained consciousness within a few seconds he complains of
headache, nausea and Lightheadedness which got better with food intake the patient
has been sweating profusely and complaints of decreased urine frequency and dry
mouth. His vital signs show blood pressure of 116/78 with an increased heart rate of
108 and temperature 99.1F. upon physical examination
patient's clothes were drenched in sweat. He appears slightly pale and has
tachycardia. He has a capillary refill of three seconds for his fingers. risk factors
include antihistamine use, alcohol, high heat index and obesity.
Differential Diagnosis-
Heat Exhaustion- (Primary Diagnosis)- T67.5XXA
My primary diagnosis is heat exhaustion because the patient was involved in high-
intensity
physical activity with a high heat index of 100 and was inadequately hydrated,
which caused a sudden loss of consciousness. The patient had classic symptoms of
headache, lightheadedness, nausea, muscle cramps, dry mouth, and decreased
urination. His physical examination of cool,
clammy, and pale skin, capillary refill of 3 seconds, excessive sweating, orthostatic
hypotension, and tachycardia also support the diagnosis of heat exhaustion. He has
other associated risk