History of Present Illness
Review of Systems
Past Medical History
Physical Examination
Differential Diagnosis
Relevant Testing
Lab Result
Diagnosis 1
Relevant Next Steps
Test Result
Diagnosis 2
Treatment Orders
Question 1
Question 2
Question 3
Question 4
About the Case
Weight loss and dizziness in a 29-year-old man
Review of Systems
General
: 12-kg weight loss and slightly decreased appetite. No fever or chills.
Skin
: Recent onset darkening of his nipples and the knuckles of his hands. No rash or lesions.
HEENT
: Noncontributory
Pulmonary
: Mild exertional shortness of breath, which is new. No cough.
Cardiovascular
: Occasional palpitations and lightheadedness on standing up, which resolves after a few minutes. No chest pain, no peripheral edema.
Gastrointestinal
: Bowel movement once daily with normal stool, morning nausea with occasional non-bloody vomiting, and generalized mild abdominal pain that is unrelated to meals, position, or activity.
Genitourinary
: No dysuria or increased urinary frequency or volume.
Musculoskeletal
: Generalized mild weakness; he struggles to get through a day’s work as a builder. No swelling or pain in legs, joints, or muscles.
Neurologic
: Noncontributory
Psychiatric
: Low mood for the last 2 months due to tiredness.
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