Spells (nonspecific)

CC: Faintness
Focus: neurologic, cardiovascular, pulmonary system, mental health
onset: yesterday when standing up from supine position, after TURBT
accompanied symptoms: diaphoresis

cardiovascular:

• History of hypertension, TIA, myocardial infraction, or arrhythmia: denied
• Accompanied tachycardia, palpation: none
• Normal heart sound
  
• BP measure: 120/90
• Pitting edema, jugular vein distention: none
• Blood loss: gross hematuria, blood loss during cystoscopy
• RBC 4.47*10^6, Hb 14.4 g/dL, Hct: 41.2%, all within normal range (exam date: 2008/1/9)
  

pulmonary:

• History of COPD, chronic cough: denied
• Accompanied tachypnea, palpation: none
• Normal breathing sound

neurologic:

• Visual deficit, blurred vision, numbness, tingling, weakness on one side: none
• Headache: denied

medication:

• Unremarkable

other:

• Sodium: 133 (exam date 2008/1/9)
• BUN:30 (exam date 2008/1/9)

Summary:

• Rule out TIA: history of TIA(-), neurologic deficit(-)
• Rule out hypertension: history of hypertension(-), normal BP, headache(-), vomiting or nausea(-)
• Rule out arrhythmia: history of arrhythmia(-), tachycardia(-), palpation(-) (should check EKG)
• Rule out heart failure: history of heart failure (-), pitting edema(-), jugular distention
• Rule out MVP: normal heart sound
  
• Rule out pulmonary relation origin (pulmonary embolism) : history of SOB, COPD, chronic cough(-), tachypnea(-), normal breathing sound, symmetric chest wall expansion, normal oxygen saturation
• Rule out dehydration: moist oral mucosa, good capillary refill, normal BP, no thirst
  

Assumption
1. Postural hypotension, rule in blood loss-related (after TURBT, raise the possibility of blood loss)

Plan
CBC
Because he concerns about the possibility of anemia and has poor feeding recent days, he asks for additional nutrition supplement through IV (self-pay).
Check BUN, Cre (reason: previous high level of BUN and to rule out hypovolemia)

2. Possible hyponatremia (may cause altered consciousness). Surgery of TURBT, possible dilutional effect

Plan
Check sodium level