Name: Samuel Johnson

Medical Record #: N283749

DOB: 03/15/1978
Patient Room: 34
Date of Presentation: 07/24/2019
Chief Complaint: Nausea and multiple headaches throughout the day
History of Present Illness: Patient is a 41-year-old male with history of
back pains and high blood pressure. Patient comes in today
complaining of severe headaches, nausea and constant vomiting. He
says hes been feeling this way for two weeks now. He says he woke up
one morning feeling the pain unexpectedly. Patient says the pain is
gradually getting more intense and is spreading throughout body.
Patient has no history of smoking. Patient has no history of illnesses.
No history of trauma to the cranial.
Past Medical History:
Active-Hypertension
Inactive-Appendicitis. Removal of appendix 06/15/1999. Fractured
radius 09/22/2002.
Family History:
Father-Prostate cancer at age 35. Lost life to cancer in 2006.
Mother-Biopsy done at age 28. Clear results.
MEDs:
Lisinopril
Cozaar
Losartan
Physical Exam:
Vital signs: Ht 602 Wt 190 HR 80 BP 125/75 Vision 12/20. Patient has a
lump on the dorsal portion of the cranial.
Assessment:
Gradual loss of vision and consistent emesis. Lump on posterior head
may be abnormal growth of tissue. No symptoms of fever or sickness.
Symptoms of brain cancer present.
Plan:
1. Have a blood count completed to rule out cancer
2. Blood protein testing to rule of cancer
3. Biopsy to rule out cancer
Final Resort:
30 mg of Phenobarbital