TRANCRIPT OF A GOOD ORAL H&P Source of informations is the patient, Mrs Jones, with additional information provided by her husband. Both appear reliable. The chief complaint: Mrs Jones is a 80 year old woman, with HTN presenting with 2 episodes of syncope over the last week. HPI: Mrs. Jones was in her usual state of health until (usually starts with this sentence) a four weeks ago (chronology is extremely important), at which time she noted the onset of lightheadedness. These episodes usually occurred while walking, lasted for a few minutes at a time and spontaneously resolved upon sitting down. They initially occurred about once every two to three days, there were no associated symptoms, including chest pain, SOB, or palpitation. Over the next three weeks they became more frequent, eventually occurring several times a day (QILTF2ADC BEING APPLIED HERE). One week ago, she stood up from the dinner table to walk across the kitchen and suddenly felt lightheaded for a few seconds and passed out. She woke on the ground seven second later, where she stayed for a couple of minutes while her lightheadedness passed. She then got up, rested in the chair for another five minutes, before feeling completely back to normal. She denies hitting her head at that time. The event was witnessed by her husband who reported no jerking motions of the arms or legs no incontinence and no significant confusion after she woke (overall evolution of the symptoms and important events). Her husband wanted to bring her to the ER but she declined because she was afraid of being admitted. Since then she has continued to experience intermittent lightheadedness, continuing to become more frequent until recurrent episode of passing out on the day of admission that was identical to the first. Her husband called 911 and paramedics then brought her to the hospital. Mrs Jones currently reports feeling fine and is asking to go home (Current status). When asked what she thinks might be causing her symptoms she states that she should be staying better hydrated (patient’s perception of illness). PMH - Medical o Mrs. Jones has an MI in 2012, but has had no history of HF. o She also has had diabetes for 20 years with recent HB A1C of 8.5%, diabetic peripheral neuropathy and osteoarthritis. - Surgical o Surgical history includes only an appendectomy 40 years ago - Ob/GYN - Psych o She has no significant gynecological or psychiatric history Medications - Medication include o Aspirin o o o o o o Metoprolol Lisinopril Simvastatin Metformin Amitriptyline, the last of which she was recently started on for her neuropathy She takes no herbal supplements and she reports 100% adherence to all medications Allergy / adverse drug reactions: - She has had no adverse drug reactions Social history - For her social history she is a nonsmoker and drinks one to two glasses of wine per night. - She denies any use of recreational drugs. - She currently lives in downtown Palo Alto in a single-family home with her husband. Family history -Her family history is “non-contributory” Ros -ROS was negative aside from what was covered in the HPI PE - - - On exam, she is a well-nourished elderly woman who appears her stated age and it is in no apparent discomfort. Temperature is 98.4 / heart rate 58 / supine blood pressure 134 over 70 which decreases 110 over 65 upon standing / respiratory rate 14 and O2 sat of 96% on room air She has no carotid bruits. Her cardiac exam reveals a normal sinus rhythm, normal S1 S2, two out 6 early systolic murmur at both upper sternal borders without radiation, no S3 or S4. JVP is about 6 centimeters. Pulmonary, abdominal, extremity and skin exams are all normal. A thorough neuro exam was unremarkable with the exception of diminished sensation to light touch in both feet along with absent ankle reflexes bilaterally. Her gait is slow without other abnormalities. Labs / diagnostics - Labs demonstrated unremarkable CBC and CMP. BNP is 220 and troponin is less than 0.07 (See, here even the negative labs are important, because they matter in Dx) - UA show only 1+ protein - Chest X-ray demonstrated mild cardiomegaly and probable osteopenia. - An EKG reveals non-respiratory sinus rhythm with a rate of 56 and first-degree AV block, with a PR interval of about 250 milliseconds, shows Q waves in two, three and AVF and has evidence of LVH by voltage criteria. Linking statement - So, in summary, Mrs. Jones is a 80 year old woman, with a past medical history of MI and diabetes who presents with subacute, progressive, positional lightheadedness, culminating in two recent episodes of syncope her exam is notable for mild orthostatic hypotension and early systolic murmur unremarkable labs and an EKG with evidence of mild conduction system disease. Assessment and Plan #Problem number one is her lightheadedness and syncope. Given the combination of orthostasis by history and exam and recent medication change, orthostatic hypotension secondary to amitriptyline is the most likely diagnosis particularly as this is one of the most frequent observed meds to cause this problem. Closely related to this possibility there is a chance that she may have autonomic dysfunction from diabetes as the presence of neuropathy suggests her diabetes has been long standing and not optimally controlled. Less likely, but still an important consideration is bradyarrhythmia such as severe sinus bradycardia or intermittent high AV block her EKG suggests a presence of conduction system disease and bradyarrhythmias are a relatively common cause of syncope in the elderly, however this is not typically positional as she describes her symptoms. A don’t miss diagnosis for Mrs. Jones is ventricular tachycardia which she is at risk for, given her prior MI, but otherwise, nothing else is suggestive of this diagnosis. Her heart murmur is consistent with aortic stenosis, though the murmur’s character is not consistent with the severity of AS that would be necessary to cause syncope. - Diagnostic plan o The diagnostic plan for her syncope includes telemetry monitor for 24 hours, followed by a 2-week ambulatory monitor if the diagnosis remains unclear at discharge. She will receive an echo to rule out artic stenosis. - Therapeutic plan o Something which spans her diagnostic and therapeutic domains, we will DC her amitriptyline and monitor her for resolution of her orthostasis over the next several weeks as an outpatient. - Educational plan o For education, we want to instruct Mrs. Jones to from a lying to standing positional over the course of several minutes. # Problem number two is her CAD for which we are going to continue all her previous cardiac meds. In the event that her telemetry picks up more significant bradycardia we will need to discuss the risk benefit ratio of discontinuing the metoprolol # Problem number 3 is her diabetes. As she will likely be eating normally and we do not anticipate any upcoming contrast studies, we will continue her outpatient metformin. For her neuropathy we are discontinuing her amitriptyline. To avoid confounding presentation we will hold off on adding new meds for now, but we are considering gabapentin at some point in the future. Diet o For diet she will be on standard carb control diet Prophylaxis o For prophylaxis we are encouraging ambulation we will start subcutaneous heparin And finally, her primary stated goal of care is to get home as soon as possible, preferably with her lightheadedness resolved. She cleared states that in the event of a cardiac arrest, she would not want to receive attempts at resuscitation and would be strongly opposed to an ICU admission. As such we are placing a DNR/DNI order in her chart.