I HUMAN CASE WEEK 7 COMPREHENSIVE
CLINICAL EVALUATION DIAGNOSTIC REASONING,
AND EVIDENCE BASED MANAGEMENT OF A 65
YEAR OLD MALE PRESENTING WITH
PROGRESSIVE NAUSEA CHRONIC FATIGUE
FUNCTIONAL DECLINE AND MULTIPLE
COMORBIDITIES IN PRIMARY CARE
,PATIENT INFORMATION
Name: Withheld for privacy
Age: 65 years
Gender: Male
Height: 5′8″ (173 cm)
Weight: 204.0 lb (92.7 kg)
BMI: 31.0 kg/m² (Obesity Class I)
Encounter Type: Outpatient primary care visit
Clinical Setting: Facility with laboratory testing, ECG, and
imaging capabilities
Reason for Encounter: Nausea and fatigue
, REASON FOR ENCOUNTER (TABLE FORMAT)
Category Clinical Details
Chief Complaint “I feel nauseated and exhausted most days.”
Onset Gradual onset over 2–3 weeks
Duration Persistent, daily
Associated Early satiety, decreased appetite, reduced
Symptoms energy
Aggravating Factors Morning hours, exertion
Relieving Factors Partial relief with rest
Functional Impact Difficulty completing daily activities
CLINICAL EVALUATION DIAGNOSTIC REASONING,
AND EVIDENCE BASED MANAGEMENT OF A 65
YEAR OLD MALE PRESENTING WITH
PROGRESSIVE NAUSEA CHRONIC FATIGUE
FUNCTIONAL DECLINE AND MULTIPLE
COMORBIDITIES IN PRIMARY CARE
,PATIENT INFORMATION
Name: Withheld for privacy
Age: 65 years
Gender: Male
Height: 5′8″ (173 cm)
Weight: 204.0 lb (92.7 kg)
BMI: 31.0 kg/m² (Obesity Class I)
Encounter Type: Outpatient primary care visit
Clinical Setting: Facility with laboratory testing, ECG, and
imaging capabilities
Reason for Encounter: Nausea and fatigue
, REASON FOR ENCOUNTER (TABLE FORMAT)
Category Clinical Details
Chief Complaint “I feel nauseated and exhausted most days.”
Onset Gradual onset over 2–3 weeks
Duration Persistent, daily
Associated Early satiety, decreased appetite, reduced
Symptoms energy
Aggravating Factors Morning hours, exertion
Relieving Factors Partial relief with rest
Functional Impact Difficulty completing daily activities
