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    Diagnosis Present Illness

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    Case Study Two

    Present Illness

    Mr. Irving is a 45-year-old African American male who comes in for follow-up of his hypertension. The patient was due back for follow-up 1 month after starting his medication, but he was too busy to come in. He complains of a dry cough that has not responded to over-the-counter (OTC) Robitussin® and that keeps him awake at night. He has been feeling tired for the past few months, but he has attributed that to not sleeping well. He also complains of constipation. He denies chest pain, shortness of breath, edema, change in eating habits or activity patterns, sputum production, postnasal drip, or runny nose.

    Medical History

    None reported

    Family History

    Mr. Irving's mother died at age 65 from a stroke. His father died at age 55 from a heart attack. Mr. Irving's two brothers are living in good health, although one has high cholesterol.


    Daily multivitamin, Lisinopril 10 mg qd, OTC Robitussin®, and OTC stimulant laxatives prn
    Lisinopril 10 mg qd, beginning 6 months ago


    None reported

    Social History

    He is a divorced father of one who teaches sixth grade.
    Patient does not smoke or drink.

    Physical Examination

    This is a w/n, w/d black male with good eye contact, appropriate speech and mannerisms, appropriately dressed and who states he wants to be seen for control of his blood pressure. He does not have any noticeable rash or excessive dryness of his skin.

    HT-6 ft, WT 205 lbs
    BP 148/110, P - 80 & regular, BMI 28

    Abbreviated exam: Chest CTA, Cardiac NSR without murmurs, abd soft, nontender, liver nonpalpable, nontender, no peripheral edema noted


    TSH -5.2 (0.5- 4.5)
    Free T4 - 0.8 (0.8-1.7)
    Free T3 - 1.8 (2.0-4.8)
    Creatinine - 2.1 (0.8 - 1.4)
    BUN - 22 (7 - 20)
    CMP is otherwise normal.
    CBC is normal.


    No tests were performed.

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    Solution Preview

    Profile of patient:
    dry cough
    feeling more tired than usual (exhaustion)

    Lab Levels
    TSH is high
    Free T3 is low
    Creatinine is high
    BUN is high

    The high TSH and low free T3 are an indicator of hypothyroidism, or an underactive thyroid. ...

    Solution Summary

    Case study on patient Mr. Irving. Analysis of his symptoms and diagnosis. The medical history, family history, medications, allergies, social history and physical examination are used for the diagnosis.