SOAP NOTE

Name: M.S

Pt. Encounter Number:

Date: 06/12/2018

Age: 65

Sex: Female

SUBJECTIVE

CC: “I feel very dizzy when getting up the bed”

HPI:

65 years old female with PMH of HTN, non- insulin dependent diabetes mellitus complains of dizziness for the last 2 days.

Medications: (List with reason for med)

Metformin 500 mg 1 tablet by mouth BID for diabetes

Lisinopril 10 mg 1 tab by mouth daily.

PMH: HTN, non- insulin dependent diabetes mellitus

Allergies: NKA

Medication Intolerances: None

Chronic Illnesses/Major traumas: None

Hospitalizations/Surgeries: No recent hospitalization or previous surgery.

Family History:

Father and Mother deceased

Social History

Patient is a retired office clerk, married for 46 years. Denies tobacco, alcohol, or illicit drug use.

ROS

General:

Reports weakness. Denies weight changes, fevers, malaise.

Cardiovascular;

Denies chest pain, palpitations, orthopnea, edema, SOB.

Skin

Denies dry or itchy skin. No rashes, bumps, or sores. No bruises, no moles changing in shape color or size. No changes in hair or nails. Reports diaphoresis.

Respiratory

Denies waking up at night short of breath, no SOB on exertion, no cough, no pain on respiration. Denies hemoptysis, wheezing, or pleurisy. Denies having asthma, bronchitis, emphysema, pneumonia, or tuberculosis.

Eyes:

Reports wears reading glasses 

Gastrointestinal

Denies constipation, nausea or vomiting hepatitis, hemorrhoids, ulcers, black tarry stools. Last bowel movement was today. Denies abdominal pain, food intolerance or excessive belching or passing gas

Ears

Denies hearing loss, ear pain or discharge

Genitourinary/Gynecological

Denied been sexually active, any abnormal vaginal bleeding. No breast complaints. Last Pap and mammogram were done in November of 2017 which were normal. Menopause at age 45. Gravida 1, para 1.

Nose/Mouth/Throat

Denies nasal congestion, sore throat, or dental problems.

Musculoskeletal

Denies back pain, swelling, stiffness or fracture. Denies joint swelling. Denies history of osteoporosis. No assistance to be transfer

Breast

No lumps, bumps or abnormalities

Neurological

Denies any head injuries, near syncope or syncopal episodes, vertigo, seizures, headaches, numbness, paresthesia, tremor, gait instability, falls, or memory loss.

Heme/Lymph/Endo

Denies recent blood transfusions, night sweats, changes in eating pattern or intolerance to changes in temperature.

Psychiatric

Denies depression, anxiety, sleeping difficulties, suicidal ideation/attempts, and previous dx

OBJECTIVE

Weight: 148 BMI 26.2

Temp: 98.8 BP: 134/67

Height 5 feet 3 inches

Pulse 76 Resp: 18

General Appearance

Patient appears in no apparent distress, comfortable, behavior is appropriate for age, cooperative

Skin is cold to touch, no rash, wounds, erythema or skin lesions noted. Diaphoresis noted.

HEENT

Head is normocephalic, atraumatic. Symmetric facial expression. PERRLA. Neck is supple. Trachea midline. No lymphadenopathy.

Cardiovascular

S1 and S2 present. No carotid bruit. Normal heart rate and rhythm.

Normal breath sounds bilaterally with good air movement. Respiratory pattern is regular, symmetrical.

Abdomen is flat, non-tender. Bowel sounds active in 4 quadrants. No guarding or rebound tenderness. Reports nausea.

Deferred

Genitourinary

Deferred

Patient with full ROM in all extremities.

Equal bilaterally, normal gait, no paralysis, and normal speech ad normal facial asymmetry. Reports weakness and near syncope.

Level of consciousness is awake and alert, obeys commands, AAO x 3. Denies suicidal ideas or ideas of harm to others

Lab Tests

Random plasma glucose: 53 mg/dl

HbA1C- Pending

Special Tests: None

Diagnosis

o Differential diagnosis

· Orthostatic hypotension: This condition is precipitated by suddenly standing up after a long period of sitting or lying down. Other causes include medications that affect blood pressure, history of Parkinson’s disease, diabetes or Shy- Drager syndrome (Ricci, De Caterina & Fedorowski, 2015). In addition, patient taking alpha blockers such as Tamsulosin are at increased risk for orthostatic hypotension (Ricci, De Caterina & Fedorowski, 2015).

· Hypoglycemia: This condition is the result of blood sugar levels less than 60 mg/dl. Hypoglycemia can be caused by many factors including high levels of insulin in the body, presence of a sulfonylurea, growth hormone deficiencies, extraneous exercise, and lack of adequate nutrition, prolonged fasting, and others (Lin, 2016). It’s characterized by weakness, dizziness, cold skin, diaphoresis, faintness, nausea and drowsiness (Lin, 2016).

· Final diagnosis: Hypoglycemia

Plan: 

· Administer Glucagon 1mg IM

· Accu Checks q 15 minutes until blood sugar is over 80 mg/dl

· Decrease Metformin to 250 mg 1 tablet BID by mouth

· Order HbA1C to assess blood glucose control over a longer period of time (Lin, 2016).

· Follow up in 1 week for lab results

· Educate patient to recognize signs and symptoms of hypoglycemia.

· Educate patient to always carry snacks or life savers candies with her.

· Educate patient to eat small but frequent meals throughout the day. Never go more than 3 hours without eating.

Reference:

Lin, C. H. (2016). A probe into the analysis of cause of hypoglycemia among patients joining diabetes health improvement program. Diabetes Research and Clinical Practice, 120, S162. doi:10.1016/S0168-8227(16)31349-3
Ricci, F., De Caterina, R., & Fedorowski, A. (2015). Orthostatic hypotension. Journal of the American College of Cardiology, 66(7), 848-860. doi:10.1016/j.jacc.2015.06.1084.