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William SaliskiGeriatric SOAP Note Subjective DataAS - This is a 94 yo Caucasian male that is recently widowed. He is accompanied to the clinic today with his sitter but all of the information was given by him. CC - "Real dizzy, laid back down and got back up but still dizzy, weak and shaky feeling when getting out of bed this am."HPI - To preface, AS has colon adenoma which needs surgery and has required blood transfusions for in the past but has not had any time to potentially need surgery for. This am he woke up and everything began spinning. He went back to bed and got up 15min later where he called his sitter and EMS. EMS said his vitals were normal and did not do anything else. He is not as dizzy but feels "woozy" now. Does not check his blood sugars at home. Had not eaten breakfast.Location - He feels weak, woozy, and unbalanced in his head. Quality - Slightly dizzy, woozy, and low energy. Feels unbalanced when he stands. Severity - Mild. Can get up and walk around but feels light headed and slightly lightheaded. Does not impact his normal ADLs. Just feels rundown.Timing - Just started this am and has been happening for about the past 4 hours. Has not had an episode such as this before. Setting - Lying down to standing is when he feels more unbalanced and dizzy. Walking around he is slightly dizzy but not as bad as when he stands. Alleviating and Aggravating factors - There are no alleviating factors since he feels the same when he is sitting as when he is standing. Aggravating factors are when he goes from a seated to standing position but this is not as severe as it was this am. It does not really happen that bad when he moves his head from side to side or look up and down. Associated S&S - has colon adenoma which needs surgery and has required blood transfusions for in the past due to a low H&H. Denies any rectal bleeding and he is currently taking iron. Recent H&H was 10/32 and was about 3 months ago. Is on BP medications and is a diabetic. PMHMedications Aldactone 25mg tab PO QDAmaryl 2mg tab PO QDCoreg 25mg PO BIDCoumadin 5mg PO QD (on hold right now due to frequent falls)Diovan 160mg PO QDHytrin 5mg PO QDLasix 20mg PO QDProscar 5mg PO QDSynthroid 50mcg PO QDZocor 20mg PO QDAsp 81mg PO QDDiltiazem ER 180mg PO QDFerrous sulfate 300mg PO TIDImdur 40mg PO BIDPrednisone 10mg PO QDAllergies - Altace (unknown), PCN (unknown), Zithromax (unknown)Illnesses - Colon adenoma which requires surgery but does not want to have at this time, blood transfusion in March '13, CAD, HTN, CHF, BPH, DM II, polymyalgia rheumatica, Operations - Left and Right direct hernia repair '92, TURP '98, pacemaker '04Hospitalizations - March '13 for rectal bleeding and blood transfusions from the adenoma. No curative effort at this time due to wife being sick and wanting to take care of her. Thats all he can remember at this timeHealth promotion and compliance - He is currently up to date on all of his vaccinations i.e pneumonia and has had the flu shot. He is up to date on all of his annual exams from may '13 when he had his annual physical. FHParents - Both deceased and could not recall how they had dies since it has been many years ago. Can only recall that his father might have had heart disease and his mother might have had some kind of cancer.Siblings - He has one sister 88yo, still living, who has HTN, high cholesterol, and CHF.Children - He has 1 son 70yo and 1 daughter 72yo. Son - HTN, CAD, high cholesterol, RA. Daughter - HTN, high cholesterol, and osteoporosis.Grandchildren and Great grandchildren - does not know of any medical problems with them. SHHe is currently a widower of about 5 months, lives by himself and has a sitter come and help him around during the day, he is retired and just does things around the house, he is a former smoker and quit about 20 years ago where he smoked about 1 ppd, he likes his one alcoholic drink in the evening with dinner but does not drink anymore than that. He no longer partakes in sexual activities, his educational level was through high school, and his religious background is baptist. ROS Constitutional - Patient denies fever, chills, weight loss, weight gain, fatigue, daytime hypersomnolence, sleep difficulty, nor sleep apnea. Slept good last night. Drinks plenty of water throughout the day and has his occasional drink in the evening. Eyes - No real issue with eye sight and does wear glasses. Does not complain of any eye disturbances, sweeling, or pressures. ENMT - No issue with ears or signs of infection, he has hearing aids but does not use them like he should, no complaints with his nose and says he can breathe normally. No problems with his mouth and does have dentures. Last dental exam was about 6 months ago. He is able to take out his dentures and clean them every night, does not have any problems from them at this time. He does not complain of any swelling, itching, or dysphagia in his throat.\Cardio - Patient does not exercise routinely and does not complain of any cardiovascular problems. Does not complain of any activity intolerance, unusual blood pressures, chest pain, murmurs or palpitations. Does have some dizziness.Resp - Pt denies cough, orthopnea, SOB, sputum production, wheezing, hemoptysis, and congestion. Never around second hand smoke and did smoke in the past. GI - Pt negative for appetite loss, constipation, diarrhea, flatulence, heartburn, hematemesis, melena, nausea, vomiting, dysphagia, change in bowel habits, nor abdominal pain. Eats a low fat diet that is prepared for him.GU - Pt negative for dysuria, hematuria, nocturia, hesitancy, urinary frequency, polyuria, incontinence or reduced stream. No penile discharge, not sexually active, and does not have any testicular pain. Musculo - Pt does not partake in exercise at this time, does complain of some fatigue throughout the day, no joint pain at this time, or lack of range of motion. Does use safety belts in cars. Does have some weaknesses that does not allow him to be able to do all of his ADLs independently. Integ- He does complain of easy bruising with his skin and tearing easily, he does not use skin protectant regularly while outside in the sun, and he bathes once a day usually. Does not complain of any nail deformities. Neuro - Pt does complain of weaknesses but no headaches, seizures, or strokes. Does have some memory loss and says that he isn't as sharp as he used to be. Psych - No nightmares nor suicidal thoughts or tendencies. He is happy and does not complain of any depression or anxiety. Endo - No endocrine problems at this time to mention, he is at a stable weight which does not fluctuate drastically. No complaints of heat or cold intolerance during the night or day.Hem/Lymph - Does bruise easily but has been on coumadin, feels fatigue at times, history of anemia, blood transfusions, and last H&H was 10/32.Allergy/imm - Pt is currently taking steroids, does not have any seasonal allergies, and does not know of any immunocompromised family members. Objective Constitutional - Temp 98.6, weight 144lbs, height 64", BMI 24.7. He is awake, alert, and oriented x3, comfortable in setting, well nourished, no acute signs of distress, and pleasant. B/P - 143/50 HR - 71Eyes - PERRLA, eyes were normal, eyelids normal, Conjunctiva normal, sclera normal and white. ENTM - Normocephalic, no gross oropharyngeal lesions, normal position of ears with impacted cerumen bilaterally, tympanic membranes normal, nose without deformity, nose is clear and patent,mucous membranes moist and pink, tongue normal, dentures present, throat pink and moist with no signs of sores or swelling. Cardio - Regular rate and rhythm on auscultation, no murmur, capillary refill brisk, no carotid bruits or pedal swelling. Resp - Lungs clear to auscultation bilaterally, no increased work of breathing.GI - Abdomen soft and non-distended, no abdominal pain on palpation or percussion. No masses were felt on palpation. Bowel sounds are normal and active in all 4 quadrants. No organomegaly. GU - This area was not assessed due to the nature if the patients CC.Musculo - Strength is normal on standing, grips are equal, and some weakness was visualized but is normal for pt. Skin - Warm and dry, no rash was seen. Hair is normal and evenly distributed. Some bruising. Neuro - No involuntary movements noted, no weakness, or tremors seen. Pt is oriented x3 and aware of the setting and situation she is in.Cranial nerves II-XII grossly intact, no focal motor deficit, no focal sensory deficit. Psych - Pt seems to be in a calm mood and does not look depressed nor anxious while she is being examined. Hem/Lymph/Imm - Pt does have some bruising which is normal for him. There are no swollen lymph nodes noted on the patient.Orders Anemia profile - PendingChem 14 - Pending TSH and FREE T4 - PendingEKG - ventricular paced rhythm without any infarct or abnormalitiesAssessment Diagnosis 1. Dizziness/vertigo - 780.42. Anemia - 280Labs that were done were mentioned above and all are send outs so results will take 24-48 hours to receive back.Acute Self Limiting ProblemsDizziness and wooziness on standing in the morning that has continued throughout the morning. Makes him feel unbalanced and unable to perform all of his ADLs even with the assistance of his sitter.PlanMedications for treatmentAntivert 25mg tab PO TID prn dizziness.MOA - Antivert depresses labyrinth excitability and vestibular stimulation. The actions are not well understood but it is believed that the central anticholinergic actions are what plays the biggest role in decreasing vertigo in people who take this medication.Usual dosage - 25mg PO TID PRN dizziness, vertigo, or motion sicknessAvailable as both brand name or genericPublix - $18.00 cash priceWalgreens - $16.00 cash price CVS - $12.00 cash price Debrox 6.5% ear drops3 drops each ear daily for 7 days for the impacted cerumenThere were no other outside diagnostic tests ordered for this patient at this time other than the tests mentioned above. If symptoms persist after the day treatment with debrox then the patient should come back into the clinic so other tests can be ordered. Follow up should be PRN any further issues as stated above or any new onset symptoms. If no new symptoms present and these symptoms are alleviated, then next follow up will be for his yearly physical. No consultation or referrals are needed at this timePatient educationUse the ear drops exactly as prescribed and rinse the ear out while in the shower to help dislodge any impacted cerumen. Call if symptoms worsen or persist past the 7 day treatment of ear drops. Do not try to stand if feeling overwhelmingly dizzy, sit back down until you feel oriented and will not fall. Will call patient with results of lab tests and see if other treatments are advised for possible anemia or low H&H. ................
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