The episode was unwitnessed by providers but observed by his mother.
Syncope, Weakness, Anorexia, Brain Tumor15554303′. Case/ake Nine
S: 16-year-old Hispanic male with weakness and reported loss of consciousness on Sunday for approximately 2–3 minutes. The episode was unwitnessed by providers but observed by his mother. He regained awareness quickly and was oriented. No EMS called or ER evaluation performed. Patient has a history of brain tumor with surgeries in 2016 and 2020; receives monthly chemotherapy. Complaints of fatigue, shortness of breath on exertion, poor appetite, difficulty walking, and generalized weakness. Often sleeps during the day and struggles to expectorate sputum. Uses a walker or cane for ambulation.
Mother confirms poor appetite and notes he has not been eating well. Last labs (2/6/25) were WNL. No vomiting or GI symptoms. Neurology consult is scheduled in 2 weeks.
Past Medical History: Brain tumor with surgeries (2016, 2020), on chemotherapy
Social History: Lives with mother, no current school attendance due to medical condition
O:
VS: Temp: 98.6°F | HR: not taken | RR: not taken | BP: not taken | Wt: 147.6 lbs (66.95 kg) | Ht: 60 in (152.4 cm) | BMI: 28.82 (95.98%)
General: Alert, well-nourished, no acute distress
Head: Normocephalic, atraumatic.
Eyes: PERRLA, sclera anicteric.
ENT: Moist mucosa, clear throat.
Neck: Supple, full ROM, no LAD.
Skin: Warm, dry, no rashes
Heart: RRR, no murmurs, normal S1/S2.
Lungs: Clear to auscultation, good air movement
Abdomen: Soft, nontender, no organomegaly.
Extremities: No edema, no cyanosis or clubbing
Neuro: Alert, oriented x3, generalized weakness with ambulation, uses walker; no focal deficits
A:
R53.1 – Weakness.
R63.0 – Anorexia.
Z85.841 – Personal history of brain tumor.
Z51.11 – Encounter for antineoplastic chemotherapy
P:
Weakness: Safety reinforced, use of walker/cane encouraged, continue neurology referral
Anorexia: Counsel on iron-rich and calorie-dense foods: lean meats, fortified cereals, beans, greens. Vitamin B12, folate, and Vitamin C-rich foods recommended. Encourage small, frequent meals and high-calorie shakes. Monitor for weight loss and hydration status. Energy conservation techniques recommended. Moderate exercise with clearance from oncologist
Education: Emphasized nutrition, hydration, and rest. Encouraged mother to monitor for any new neurologic symptoms, prolonged fatigue, vomiting, or worsening weakness. Instructed to go to ER for any acute changes in consciousness, severe fatigue, vomiting, seizures, or breathing issues. Regular follow-up with oncology, neurology, and PCP encouraged.
Follow-Up: Neurology in 2 weeks. RTC in 3 months or sooner if symptoms worsen
