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“My dad has been complaining of headaches and is now acting confused.”
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History of Present Illness
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JK is a 68-year-old male, who was brought to the emergency department with a headache, nausea, and episodic vomiting that started about a week ago, and recent onset of dizziness, confusion, and irritability that was noticed today by his son while visiting with him for breakfast. He has a fever (101.3°F) of unknown duration. “A recent 4th generation HIV Ag-Ab test was negative.” His son states that JK lives alone and started complaining of not feeling well about a week ago.
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Type 2 diabetes, controlled with medications
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Appendectomy 20 years ago
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Father had lung cancer and passed away 40 years ago; mother had HTN and passed away from stroke 15 years ago; no siblings
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He is a retired salesperson, widowed (wife passed away from metastatic breast cancer 10 years ago), who lives alone. He has one son who visits him regularly. His hobby is golf and tending to a pet cockatoo; never smoked, but drinks alcohol occasionally
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Metformin (Glucophage XR®) 2000 mg PO daily with evening meal
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Multivitamin 1 tablet daily
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Temp 101.3°F, pulse 70, RR 20 breaths per minute, BP 130/92 mm Hg, pO2 92%, Ht 5′9″, 70 kg
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Lethargic, irritable gentleman with dizziness and confusion in moderate distress
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Normocephalic, PERRLA, EOMI, (–) papilledema, photophobia, or blurred vision
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Soft, non-distended, non-tender, bowel sounds hyperactive
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Lethargic, oriented to place and person, (–) Brudzinski’s sign, (–) Kernig’s sign, (–) nuchal rigidity
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Tenderness to palpation on lower lumbar region
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