Journal Of Contemporary Medical Research Discussion Paper
Discussion
Great post! You did an excellent job coming up with a focused soap note for the 75-year-old male patient who presented with complaints of lightheadedness, dizziness, and syncope. This post has provided a comprehensive overview of the four primary elements that make up a SOAP Note: Subjective data, Objective data, Assessment, and Plan. The patient's medical history, physical examination, and test results all point to hyponatremia being the most likely cause of his symptoms. Thus I feel that your identification of that condition as the major diagnosis for him is appropriate.
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As a result of the existence of variables that contribute to increased antidiuretic hormone and the frequent prescription of medicines that are related to hyponatremia, decreased serum sodium concentration is an electrolyte condition that occurs relatively often in the older population. Hyponatremia is becoming an increasingly important health concern as a result of many factors, including the aging of the population, the greater propensity of older people to acquire electrolyte problems, and the increased morbidity that is associated with hyponatremia in this group (Dash et al., 2019). The treatment of hyponatremia is dependent on the specific form of hyponatremia that the patient is experiencing, which you identified as hypovolemic hyponatremia. In order to prevent osmotic demyelination syndrome, extra attention must also be paid to correct blood sodium levels at the right pace, which is especially important in patients who have chronic hyponatremia (Kaspa et al., 2020)Journal Of Contemporary Medical Research Discussion Paper. Conclusively, evaluating and treating hyponatremia in an older population presents a number of obstacles due to the demographic characteristics of the patient population.
Focused SOAP Note Template This study is based on the subjective and objective health assessment of the assigned patient and the provision of information most relevant to the ongoing care for hyponatremia. This information will help clinicians form the most appropriate clinical decision and interventions like diagnostic tests and results, and care plans regarding the patient’s hyponatremia which is a commonly encountered problem. The varied etiologies of hyponatremia and the multiple formulae for its correction make it a major challenge for students and physicians alike. Also, the guidelines for the management of hyponatremia have recently been revised and in addition, new agents have become available in the market for the treatment of hyponatremia. Therefore, the objective of this paper is to appraise the clinician of the latest protocol for the management of hyponatremia. Patient Information: Mr. BR, 75-year-old, Male, Caucasian. Subjective Chief complaint (CC): Light headiness, dizziness, and syncope. History of Present Illness (HPI): Mr. BR is a 75-year-old Caucasian male who presented to the hospital with episodes of light headiness, dizziness, and near syncope over the past two weeks. The patient also reported that he had intermittent episodes of light headiness and dizziness over the last couple of weeks. He further stated that these episodes occurred while he was standing outside of his home and equally stated that it was random and not associated with any nausea or vomiting. The patient also mentioned some blurring vision, although he also had some palpitation. He stated his palpitation problem is not new to him because of his history of A-fib. He also denies any prior history of this syncope and equally denies orthostasis. However, these episodes of dizziness and lightheadedness are not associated with changes in position. The patient further reported some increased lower extremity edema. He stated that while at home, his wife took his vital signs which read thus; BP: 80s/40s and HR: 41. Current Medications: • Allopurinol 300 mg oral tablet, PO Daily. • Amlodipine, 10 mg=1 tab, PO Daily. • Aspirin, 81 mg= 1 tab, PO Daily. • Dulcolax Laxative, PO, daily. • Furosemide 40 mg oral tablet, PO daily. • Gabapentin 300 mg oral capsule, PO, 3x/day. • Pravastatin 80 mg oral tablet, PO, daily. • Xarelto 20 mg oral tablet, 20 mg= 1 tab, PO, daily with dinner. Allergies: The patient has no known drug allergy, no known food allergy, and no known environmental allergy. Past Medical History: Journal Of Contemporary Medical Research Discussion Paper
Coronary artery disease (CAD). • Chronic atrial fibrillation. • Hypertension • Congestive heart failure (EF 45%). • Obesity. Renal cancer. Pre-diabetes. Gout. Melanoma Social and Substance History: The patient is a retired teacher, who loved reading. He is married to his wife Lisa for 50 years and they leave in a single-family home with good working fire detectors. They have 3 children and 5 grandchildren. In addition, the patient denies drug, alcohol, and tobacco use. He also stated that he exercises for 30 minutes three times a week and denies talking on the phone while driving. Family History: • Mother: Deceased from diabetes and heart disease • Father: Deceased from Leukemia, heart disease Son: Living with no health conditions. • Daughter: Living but diagnosed with diabetes. • Daughter: Deceased at age 36 from breast cancer. • Spouse: Living Surgical History: • Heart surgery. Mental History: No anxiety and no depression Violence History: None reported Reproductive History: None. Review of System: GENERAL: The patient denies fever, chills, weakness, fatigue, or weight loss. Head: The patient denies suffering from head injury or trauma. Eyes: The patient denies having blurred vision, double vision, or vision loss. He equally denies suffering from eye pain or drainage from bilateral eyes. Ears, Nose, and Throat: The patient denies nasal congestion and sore throat. He also denies changes to his nose, nasal polyps, nose bleeds, sinus infections, or smelling difficulties. He also denies having chewing or swallowing difficulties as well as changes to his voice and taste. Cardiovascular: The patient denies suffering from chest pain, loss of consciousness, or heart murmurs. He however has swellings on his bilateral lower extremities, CHF, hypertension, and CAD. However, the patient reported having chronic palpitation. Respiratory: The patient denies shortness of breath, cough, or hemoptysis. Gastrointestinal: The patient denies abdominal pain, vomiting, or nausea. He also denies having hematemesis or blood in his stool. The patient denies changes to his appetite and diet, as well as denies suffering from diarrhea, constipation, or hemorrhoids. Genitourinary: The patient denies having difficulty urinating and has no known dysuria, no discharge, hematuria, polyuria, or nocturia. Skin: The patient denies having rashes and lesions. Musculoskeletal: The patient denies back, neck, and extremity pains. He also denies falls and pain and has no known history of osteoporosis. Neurological: The patient denies headache, paresthesia, and limb weakness. The patient however has + near syncope, and + lightheadedness. Psychiatric: The patient denies having anxiety and depression. Objective: Vital signs: Ht: 65 in, Wt: 171.8 lbs, BMI: 28.59, BP:145/89 mm Hg, HR: 76/min, RR: 17, Temp: 36.9 C SaO2 96-RA Physical Exam: GENERAL: The patient is a 75-year-old white male who is alert and oriented to person, time, and place. Well-developed, well-nourished, and well-groomed. HEENT: Head: Normocephalic with no bruises or lesions noted. Eye: His pupils appear to be round and non-icteric sclera. Neck: His neck is supple, non-tender, and has no masses. Cardiovascular: Have a normal rate with an irregular rhythm. Has no murmurs, no gallop, and no rubs. The patient has an abdominal aorta with no bruits noted. In addition, his peripheral pulses are intact but have peripheral edema. Abdomen: Has positive bowel sound on all four quadrants Also has no rebound or guarding. Respiratory: No shortness of breath or cough noted. His lungs are clear to auscultation Skin: His skin appears warm and dry and has no rashes or bruises. Gastrointestinal: His abdomen is soft and non-tender to touch with active bowel sounds in all quadrants. Genitourinary: The patient’s bladder is none distended. Musculoskeletal: Journal Of Contemporary Medical Research Discussion Paper
The patient is full weight-bearing 5/5 UE and 5/5 LE. The patient also has a full range of motion in all extremities. Neurological: His CN II- XII appear grossly intact. Also, no unusual motor movement or tics were noted. His pain sensation remains intact in both arms and legs as his deep tendon reflexes to both upper and lower extremities 2+. Psychiatric: The patient’s mood and affect appear appropriate and normal, with good eye contact, and normal speech. Diagnostic Results: LAB: Comprehensive Metabolic Panel W/EGFR • GLUCOSE 130 H • CREATININE 1.74 H • eGFR 54 L • SODIUM 126 L • Potassium 4.1 • CHLORIDE 85 L SERUM OSMOLALITY 250 URINE OSMOLALITY LAB: LIPASE/AMYLASE • LIPASE 100 H • AMYLASE 40 LAB: MAGNESIUM • Magnesium 1.9 CXR- hyperinflated lung fields, decreased alveolar markings apices> bases, and negative for any cardiopulmonary process (formal radiology report pending). EKG- The test reveals A-fib with a ventricular rate of 83 bpm. CT Scan: Negative for any acute intracranial abnormality. Differential Diagnosis: • Hyponatremia • Dehydration • Syncope Hyponatremia. Hyponatremia is a condition where sodium levels in the blood are lower than normal. This is caused by excess water in the body that may lead to diluting the sodium, thereby causing the condition and when severe may be life-threatening if untreated (Schrier et al., 2018). Hyponatremia is caused by an imbalance between water intake and output. In addition, patients with advanced age like Mr. BR who is 76 years old become exposed and vulnerable to hyponatremia because of the physiologic changes in their kidneys, a reduced glomerular filtration, causing an impaired capacity in diluting urine as well as impairing their ability to eliminate water. Hyponatremia is usually detected and determined through laboratory tests as a lower-than-normal sodium level in the blood and appears as sodium or Na+ in the lab results. However, the main problem in most situations is the presence of excess water that dilutes the Na+ value rather than excess sodium and as a result, the excess water moves into body cells thereby causing them to swell. This swelling may cause a major problem such as a change in a patient’s mental status that can gradually progress to seizures or coma and is frequently accompanied by changes in mental state or syncope. Also, hyponatremia can always be ascertained through a thorough medical history, physical examination, and a blood test (Fujisawa et al., 2016). According to Sahay & Sahay (2015), hyponatremia remains a very important and complicated clinical problem because both its cause and origin are multifactorial. Hyponatremia may also be euvolemic, hypovolemic, or hypervolemic. The authors further stated that the serum osmolality laboratory test is used to differentiate the various types of hyponatremias and since my patient’s serum osmolality is at the lower level of 250, I will diagnose my patient with hypovolemic hyponatremia. Similarly, based on my patient’s lab values, I will equally diagnose Mr. BR with hypovolemic hyponatremia. As a result, the treatment of hyponatremia varies with the nature, type, acute or chronic severity, and symptom. Therefore, based on my patient’s lab values, I will diagnose Mr. BR with hypovolemic hyponatremia (Sahay, M., et al. 2015)Journal Of Contemporary Medical Research Discussion Paper.
Dehydration. Dehydration is a condition that occurs when a patient’s body loses excess water as well as other fluids that the body needs to work normally or carry out its regular activities. In addition, dehydration is usually caused by severe diarrhea and vomiting, but may also be caused by not drinking enough water or other fluids, excess sweating, fever, urinating too much, or taking certain medicines (Jerónimo et al., 2017). Moreover, an individual usually gets dehydrated because the lost water or fluids was not replenished or also caused by increased urination, intake of medicines such as diuretics, blood pressure medications, or uncontrolled diabetes that always induced them to urinate more (Prieto et al., 2018). Dehydration affects all age groups, but its effects have severe and dangerous consequences on the elderly and can cause symptoms like headache, fatigue, dizziness, vertigo, and disorientation. Dehydration can equally contribute to life-threatening illnesses like heat stroke (Prieto et al., 2018). Syncope. Syncope is the medical term for fainting or passing out that is caused by a temporary drop in the amount of blood that flows to the brain. Syncope can also happen if the patient has a sudden drop in blood pressure, a drop in heart rate, or changes in the amount of blood in different areas of the patient’s body (de Ruiter et al., 2018). This is because if the patient passes out, the patient will most likely regain consciousness and alertness immediately afterward but may be disoriented for a short while. Syncope is exceptionally prevalent in elderly people and can occur in individuals with or without underlying medical issues. A form of vasovagal syncope is situational syncope and happens only when the nervous system is harmed (Solbiati et al., 2016). A few examples include anxiety, dehydration, and high levels of emotional stress. Journal Of Contemporary Medical Research Discussion Paper
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Plan. This is a 75-year-old man with a past medical history of hypertension, hyperlipidemia, MI diabetes, gout, CAD s/p CABG, chronic A. fib, prediabetes presenting to the ED for above episodes of lightheadedness and dizziness, syncope with no actual syncope over the past 2 weeks. Based on the medical conditions, Mr. BR was ordered to start with Sodium Chloride tablet 1 gm twice daily and discontinue Furosemide 20mg tablets daily for one week. Also, a stat Troponin level was ordered with further consultation with a cardiologist for possible ECHO. Will initiate IVF Normal saline at 75ml/hrs. We will equally encourage Mr. BR to drink about 1200 ml of water daily. We will initiate strict intake and output monitoring because the patient has a history of CHF, we don’t want to overload the patient with fluid. placed order for serial serum electrolyte monitoring and daily weight. The patient will also be placed on fall prevention protocol and instructed to call for assistance before getting out of the chair or bed. Will place patient on telemetry and order daily lab draws for CBC and BNP. We will also request for physical and occupational therapy evaluation prior to discharge. Also, place the patient on fluid restriction to help increase the concentration of sodium in the blood. Mr. BR is most likely hyponatremic due to the lack of fluid intake and being on a diuretic. However, since she does have a past cardiac history, we want to make sure this incident was not cardiac-related and make sure she sees her Cardiologist for R/O and issues. Questions for the Class: The treatment for hyponatremia is challenging especially with rapid correction. What are some complications when the hyponatremia is rapidly corrected? Define hypervolemic and euvolemic hyponatremia, and how can they be treated? What are some complications of hyponatremia? References de Ruiter, S. C., Wold, J. F. H., Germans, T., Ruiter, J. H., & Jansen, R. W. M. M. (2018). Multiple causes of syncope in the elderly: diagnostic outcomes of a Dutch multidisciplinary syncope pathway. EUROPACE, 20(5), 867–872. https://doi.org.ezp.waldenulibrary.org/10.1093/europace/eux099 Fujisawa, H., Sugimura, Y., Takagi, H., Mizoguchi, H., Takeuchi, H., Izumida, H., Nakashima, K., Ochiai, H., Takeuchi, S., Kiyota, A., Fukumoto, K., Iwama, S., Takagishi, Y., Hayashi, Y., Arima, H., Komatsu, Y., Murata, Y., & Oiso, Y. (2016). Chronic Hyponatremia Causes Neurologic and Psychologic Impairments. Journal of the American Society of Nephrology: JASN, 27(3), 766–780. https://doi.org.ezp.waldenulibrary.org/10.1681/ASN.2014121196 Jerónimo, R. A., Segura, J. M., & Amorós, M. M. A. (2017). Dehydration in the elderly. Nutricion Hospitalaria, 32(S2), 22. https://doi.org.ezp.waldenulibrary.org/10.3305/nh.2015.32.sup2.10275 Prieto, E. C., Suárez, S. G., & Ludeña, V. P. (2018). Conditions of fluid intake in the elderly. Nutricion Hospitalaria, 32(S2), 24. https://doi.org.ezp.waldenulibrary.org/10.3305/nh.2015.32.sup2.10280 Sahay M, Sahay R. (2015). Hyponatremia: A practical approach. Indian J Endocrinol Metab. 18(6):760-71. https://www.doi:10.4103/2230-8210.141320. Schrier, R. W., Lehman, D., Zacherle, B., & Earley, L. E. (2018). Effect of furosemide on free water excretion in edematous patients with hyponatremia. Kidney International, 3(1), 30– 34. https://doi-org.ezp.waldenulibrary.org/10.1038/ki.1973.5 Solbiati, M., Sheldon, R., & Seifer, C. (2016). Managing Syncope in the Elderly: The Not So Simple Faint in Aging Patients. Canadian Journal of Cardiology, 32(9). 1124-1131. https://doi-org.ezp.waldenulibrary.org/10.1016/j.cjca.2016.04.005 Journal Of Contemporary Medical Research Discussion Paper
References
Dash, S. C., Sundaray, N. K., Rajesh, B., & Pagad, T. (2019). Hyponatremia in elderly in-patients. JOURNAL OF CLINICAL AND DIAGNOSTIC RESEARCH. https://doi.org/10.7860/jcdr/2019/39957.12554
Kaspa, C., & Shankar Govindu, A. (2020). Clinico-etiological profile of hyponatremia among elderly patients admitted to a tertiary care hospital, Guntur. International Journal of Contemporary Medical Research [IJCMR], 7(2). https://doi.org/10.21276/ijcmr.2020.7.2.40 Journal Of Contemporary Medical Research Discussion Paper