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Medical case presentation

Boulanger David

medicine student

Identity

Name: Johnson

Forname: William

DOB: 24th September 1979

Occupation: Teacher (school director)

Social status: Married

Child: 2 (girl: 12 boy: 8)

Live in: Grenoble (France)

Symptom(s)

- Dizziness

- Headache

- Muscle aches

- Insomnia

- Nausea and vomiting

- Irritability

- Loss of appetite

- Swelling of the hands, feet, and face

- Rapid heartbeat

- shortness of breath with physical exertion

- Coughing

- Chest congestion

- Pale complexion and skin discoloration

- Inability to walk or lack of balance

- Social withdrawal

Family history (FH)

Family history (FH)

FATHER: myocardial infarction (67)

MOTHER: Diabetes (32)

Siblings: NAD

TIME

Past medical history

Past medical history

appendectomy (14)

tonsillectomy (15)

withdrawal of wisdom teeth (18)

Broken leg (23)

TIME

Social history (SH)

Social history (SH)

Swimming

Walking

Trekking

Climbing

Skiing

TIME

Examination (O/E)

examination (O/E)

Weight: 70

Size: 1.75

Weight: 70

Size: 1.75

BP: 140/80

BP: 140/80

P: 180

P: 180

Respiratory frequency

20 / Min

Respiratory frequency

20 / Min

P02: 92%

P02: 92%

T: 37.5°C

T: 37.5°C

DIAGNOSIS

DIAGNOSIS

?

Acute Mountain Sickness (AMS)

Treatment

Medications :

acetazolamide, to correct breathing problems

blood pressure medicine

lung inhalers

dexamethasone, to decrease brain swelling

aspirin, for headache relief

Other treatments

Lower altitude

Lower altitude

At rest

At rest

Water

Water

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