• Patient Information: -Name/Gender/Race: Valentina Palmero/Female/Caucasian -DOB: 12/4/1992 -Age: 24 years -Date of exam: 4/12/17 • Chief Complaint: Night sweats and unexplained weight loss. Patient says she has recurring episodes of extreme perspiration, soaking her clothes and bedding during sleep. Patient also notes that she has been losing weight for no apparent reason, dropping 10 pounds in a month. • History of Present Illness: The patient is a 24 year old female complaining of night sweats, unexplained weight loss as well as chronic fatigue and pruritus. Patient has noticed that her lymph nodes in her neck are swollen, but they are painless. Patient also complains of occasional abdominal pain. The frequency of night sweats is about twice every night, waking her up and disrupting her sleep. Frequency of pruritus is about 3-4 times a day, with itching that occurs all over her body. Fatigue is constant, with waves of extreme tiredness occurring during the afternoon and early evening. • Review of Systems: Respiratory System: -Shortness of breath- After small amounts of exercise -Coughing- Frequent productive coughing accompanied by phlegm and sputum -Chest discomfort- Chest feels tight and full, usually when walking Musculoskeletal System: …show more content…
CBC was administered to determine the WBC and platelet count and to confirm/rule out leukemia and anemia. Lymph node biopsy was completed to observe whether or not Reed-Sternberg cells are present, confirming/denying the presence of lymphoma. X-ray: Medium-sized mass present in the mediastinum. PET-CT scan: Shows enlarged lymph nodes in the chest and spleen. CBC: Normal WBC and platelet levels, ruling out leukemia and anemia. Excisional Biopsy: Reed-Sternberg cells are present in the lymph nodes, confirming