Posted: May 19th, 2023

Patient is a 75-year-old female with a chief complaint of dizziness

Select a geriatric patient that you examined during the last 3 weeks. The patient you select should be currently taking at least five prescription and/or over-the-counter drugs. With this patient in mind, address the following in a SOAP Note: Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding his or her personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking

. Compare this list to the Beers Criteria and consider alternative drugs if appropriate.

Objective: What observations did you make during the physical assessment? What functional assessments were used? Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from top priority to least priority. Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management including alternative therapies? What is your care plan for patient? How would you offer caregiver support? Reflection notes: What would you do differently in a similar patient Assessment? How might you improve your assessment, diagnosis, and/or plan through interprofessional collaboration?

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Subjective

Patient is a 75-year-old female with a chief complaint of dizziness.
She reports that she has been feeling dizzy for the past few weeks, especially when she stands up quickly.
She also reports that she has been feeling lightheaded and nauseous.
She has no other symptoms.
She has a past medical history of hypertension, diabetes, and hyperlipidemia.
She is currently taking the following medications:
Lisinopril 20 mg daily
Metformin 500 mg twice daily
Atorvastatin 10 mg daily
Aspirin 81 mg daily
Tylenol 325 mg as needed for pain
She does not smoke or drink alcohol.
She is married and has two adult children.
She lives independently in her own home.
Objective

General: The patient is a well-developed, well-nourished female in no acute distress.
Vital signs: BP 140/90 mmHg, HR 80 beats/minute, RR 16 breaths/minute, SpO2 98% on room air.
HEENT: Pupils are equal, round, and reactive to light. Sclerae are anicteric.
Neck: No jugular venous distension. No carotid bruits.
Lungs: Clear to auscultation bilaterally.
Heart: Regular rate and rhythm. No murmurs, gallops, or rubs.
Abdomen: Soft, non-tender, non-distended. No hepatosplenomegaly.
Extremities: No edema. No clubbing.
Neurological: Alert and oriented x 3. Cranial nerves II-XII intact. Motor strength 5/5 throughout. Sensory exam intact. No ataxia.
Assessment

Differential diagnoses:
Postural hypotension
Orthostatic hypotension
Hypoglycemia
Medication side effect
Plan

Diagnostic tests:
Standing and sitting BP
Fingerstick glucose
Medication review
Treatment and management:
If postural hypotension is diagnosed, recommend increasing salt intake and avoiding standing for prolonged periods of time.
If orthostatic hypotension is diagnosed, recommend increasing salt intake, avoiding standing for prolonged periods of time, and using elastic stockings.
If hypoglycemia is diagnosed, recommend checking blood sugar levels regularly and treating with carbohydrates as needed.
If medication side effect is suspected, recommend discussing with the prescriber to see if a different medication can be used.
Care plan:
Educate the patient about the signs and symptoms of postural hypotension, orthostatic hypotension, and hypoglycemia.
Instruct the patient to take their blood pressure regularly and to report any changes to their healthcare provider.
Provide the patient with a list of foods that are high in salt and carbohydrates.
Encourage the patient to exercise regularly.
Refer the patient to a registered dietitian for Helpance with meal planning.
Caregiver support:
Encourage the caregiver to learn about the patient’s medical conditions and how to manage them.
Provide the caregiver with resources, such as books, websites, and support groups.
Refer the caregiver to a social worker for Helpance with emotional support and practical needs.
Reflection notes

In a similar patient Assessment, I would ask more detailed questions about the patient’s dizziness, such as how long it lasts, what makes it better or worse, and if it is associated with any other symptoms.
I would also perform a more thorough physical exam, including a neurological exam.
I would discuss the patient’s medications with the prescriber to see if any of them could be contributing to the dizziness.
I would also refer the patient to a physical therapist for balance and gait training.
I believe that interprofessional collaboration is essential in providing quality care to geriatric patients. By working together with other healthcare professionals, such as nurses, pharmacists, social workers, and physical therapists, we can provide comprehensive care that meets the unique needs of each patient.

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