Mr. X, a 93-year-old Hispanic male, presents with complaints of dizziness and near syncope that started today with position changes

QUESTION

Case Study:

A 93-year-old Hispanic male is being evaluated for dizziness and near syncope in the long-term care facility.  Past medical history includes myocardial infarction status post stents 20 years ago on aspirin and atorvastatin; history of stroke 3 years ago with hx of aspiration & left hemiplegia uses a walker for ambulation; diabetes with neuropathy and retinopathy no longer on medication due to weight loss (diet control- dysphagia & consistent carbohydrate diet with thicken liquids); insomnia on lorazepam as needed; and cognitive impairment.  The family was unable to visit as frequently due to changes in visitation at the facility.  No history of alcohol or illicit drug abuse but former tobacco abuse 50+ years.  On Medicare and Medicaid insurance. The patient reports dizziness started today with position changes and denies changes in hearing or visual changes.  Denies new numbness or tingling; always has numbness in feet.  Denies headaches, chest pain, palpitations, and shortness of breath.  Denies nausea and vomiting but has been having some loose stools.  Today, the patient reports that when trying to go from bed to bedside commode, he felt like he was going to “blackout” but sat back down on the bed.  Finally, he reports loneliness and continued issues with insomnia, naps frequently throughout the day and night but not for long periods.  On exam, cachectic, very dry mucous membranes with poor dentition and hygiene.  Tympanic membrane bilaterally pearly gray with visible landmarks and no effusions noted.  Cranial nerves II to XII intact.  No nystagmus.  PERRLA.  Heart regular rate and rhythm.  Lungs clear to auscultation.  Abdomen soft, non-tender, non-distended, normoactive bowel sounds in all 4 quadrants.  No swelling on exam or JVD.  Sacral pressure wound non-blanchable.  Blood pressure sitting 114/67, then standing 90/54, heart rate sitting 89, then standing 104, respirations 18, oxygen 94% on room air, temporal temperature 98.3, height 5’8″ weight 119 lbs.
With the above information, construct the patient’s data into your final SOAP Note discussion board format (Celebrate and reflect on your growth!)

• If there is missing information, include what you would ask or exam based on their presentation.

1. make  a plan to help rule in or out your differential diagnoses.
2. What might you notice during this visit that could lead you to suspect the possibility of elder mistreatment?
3. What other factors might you consider important in evaluating the risk of elder mistreatment?

ANSWER

SOAP Note

Subjective

Mr. X, a 93-year-old Hispanic male, presents with complaints of dizziness and near syncope that started today with position changes. He denies any changes in hearing or visual changes. He also reports numbness in his feet, loose stools, issues with insomnia, frequent napping throughout the day and night, and feelings of loneliness. He states that he felt like he was going to “blackout” when attempting to transition from bed to bedside commode.

History of Present Illness

The patient has a history of stroke three years ago with left hemiplegia, leading to the use of a walker for ambulation. He also has diabetes with neuropathy and retinopathy, managed through diet control due to weight loss and dysphagia. The patient formerly abused tobacco for over 50 years but denies alcohol or illicit drug abuse. He takes aspirin, atorvastatin, and lorazepam as needed for insomnia.

Medication History

Aspirin
Atorvastatin
Lorazepam as needed

Past Medical History

Myocardial infarction with stents placed 20 years ago
Stroke with left hemiplegia 3 years ago
Diabetes with neuropathy and retinopathy (diet-controlled)
Insomnia

Social History

Former tobacco abuse
No alcohol or illicit drug abuse
Medicare and Medicaid insurance
Family unable to visit frequently due to changes in visitation policies at the facility

Objective

Cachectic appearance
Very dry mucous membranes, poor dentition, and hygiene
Tympanic membranes bilaterally pearly gray with visible landmarks
Cranial nerves II to XII intact
No nystagmus, PERRLA
Heart regular rate and rhythm
Lungs clear to auscultation
Abdomen soft, non-tender, non-distended, normoactive bowel sounds
No swelling, JVD
Sacral pressure wound non-blanchable
Blood pressure sitting 114/67, standing 90/54
Heart rate sitting 89, standing 104
Respirations 18
Oxygen saturation 94% on room air
Temporal temperature 98.3
Height 5’8″, weight 119 lbs.

Assessment

Dizziness and near syncope with position changes, possibly related to orthostatic hypotension.
Insomnia and frequent napping.
Loneliness and social isolation.

Plan

Orthostatic Blood Pressure Monitoring: Given the patient’s dizziness and near syncope with position changes, monitor orthostatic blood pressure to assess for orthostatic hypotension.
Medication Review: Review all medications, including atorvastatin and lorazepam, for potential interactions or side effects contributing to dizziness and orthostatic changes.
Nutritional Assessment: Evaluate the patient’s nutritional status and provide dietary recommendations to address cachexia and weight loss.
Cognitive Assessment: Perform a cognitive assessment to further evaluate cognitive impairment and consider interventions for managing loneliness and insomnia.
Referral to Specialist: Consider referral to a neurologist to assess for the possible role of stroke-related factors in the patient’s symptoms.
Elder Mistreatment Evaluation: Observe for signs of elder mistreatment, such as poor dentition, hygiene, and sacral pressure wound, and further assess the patient’s living situation and support system.
Collaborative Care: Collaborate with the facility’s healthcare team to optimize the patient’s care and address his complex needs.

Elder Mistreatment Considerations

Physical Signs: Poor dentition, hygiene, and non-blanchable pressure wound on the sacrum.
Risk Factors: Social isolation, limited family visits, and dependence on caregivers.
Further Assessment: Conduct a thorough assessment of the patient’s living conditions, interactions with caregivers, and any reports of mistreatment.

In conclusion, the case of Mr. X highlights the complex medical and psychosocial issues faced by an elderly patient with multiple comorbidities. The assessment and plan focus on addressing his dizziness, insomnia, and overall well-being while also considering the possibility of elder mistreatment and providing a comprehensive and patient-centered approach to his care.