Subjective (S)
CC: 78-year-old female complains of problems with night sleep; about once a week, the patient experiences dizziness, short-term visual disturbances after waking up. During the daytime, the patient experiences drowsiness, difficulties with thermoregulation, severe sweating of the hands and feet. She is also concerned about pain in the heart and disorders in the gastrointestinal tract, absent-mindedness or lack of coordination.
HPI
- O: one year ago;
- L: cervical spine;
- D: three months;
- C: pain in the back of the head, neck, collar area, shoulder joint; numbness of fingers; dry throat;
- A: sedentary lifestyle; hereditary predisposition;
- R: correct posture; lack of excess body weight;
- T: physical therapy; massage; vitamin B in the form of injectable drugs;
- S: the pain was relieved.
PMH
- Past illness/diagnosis: Covid-19, flu, rotavirus, conjunctivitis, acute respiratory infections, pharyngitis;
- Conditions: osteochondrosis, arrhythmia, diabetes;
- Traumas: femur neck fracture, ankle sprain, dislocation of the kneecap.
- Hospitalizations: hospitalization in the department of maxillofacial surgery for flux removal; hospitalization in the department of traumatology with femur neck fractures.
- Surgical history: flux removal; osteosynthesis.
- Allergies: Food allergy to lactose and peanuts: digestive disorder. Allergy to insect bites: wasps (swelling of the bite site). Allergy to animals: cat saliva (difficulty breathing, sneezing, puffiness and watery eyes). Allergy to dust and pollen of plants (runny nose).
- Medications: Amoxicillin intradermally: difficulty breathing, coughing and wheezing, problems swallowing food, nausea and vomiting.
Social history
- Educational level/literature: higher education;
- Smoking: passive;
- Alcohol: moderate drinking (once a week);
- Drugs: never;
- HIV risk: low;
- Sexually active: absent (the patient is in menopause for a long time);
- Caffeine: every day;
- Work: retired, not working;
- Other stressors: impressionable character;
- Cultural and spiritual beliefs that impact health and illness: prefers traditional methods of treatment to pills.
- Financial resources: average income.
Family history
Maternal: arrhythmogenic cardiomyopathy of the right ventricle –a change in the wall of the right ventricle, which led to the development of life-threatening cardiac arrhythmias.
Paternal: familial hypercholesterolemia is a very high level of cholesterol, which led to the early development of atherosclerosis of the heart vessels and, as a consequence, myocardial infarction.
Health Maintenance/Promotion
Immunizations: seasonal flu vaccinations annually;
Exercise: individually selected complex of physical therapy for elderly; daily walks in the fresh air; breathing exercises before going to bed; eye exercises.
Diet: nutrition for people with limited musculoskeletal activity, which includes animal protein sources, healthy fats, slow carbohydrates and fiber.
ROS
- General: fatigue, drowsiness;
- Skin: pale;
- HEENT: heaviness in the head and foggy consciousness; defocused vision; ringing in the ears; no complaints about the nose and throat;
- Neck: muscle pain during full rotation;
- CV: heart pain;
- Lungs: no complaints;
- GI: constipation alternating with diarrhea;
- GU: no complaints;
- PV: bright expression of blood vessels; poor blood clotting;
- MSK: bone fragility;
- Neuro: problems with memory and focus;
- Endo: no complaints;
- Psych: depressed, anxious state.
Objective (0)
PE
- Gen: fatigue (slow movements, dark circles under the eyes);
- VS: normal;
- Skin: pale, cold;
- HEENT: moderate myopia of both eyes; no other disorders were detected;
- Neck: osteochondrosis of the spine;
- CV: arrhythmia;
- Lungs: no problems identified;
- Abd: no problems detected;
- GU: no problems detected;
- PV: severe pressure drop;
- MSK: lack of calcium;
- Neuro: anxiety disorder.
Diagnostic Tests
Assessment of blood pressure level: three-time measurement of blood pressure with an interval of 3-5 minutes; determination of fluctuations in the magnitude and daily rhythm of blood pressure. An electrocardiogram was performed at rest and with stress tests.
Assessment (A)
Diagnosis: arterial hypotension –persistent and regular lowering of blood pressure below 100/60 mmHg (Knauber et al., 2018);
Pertinent positives: dizziness, transient visual disturbances, fatigue, drowsiness, tendency to fainting, unsteadiness of gait, pallor of the skin;
Pertinent negatives: disorders of the gastroenterological tract, absence of headaches and laryngeal spasms, no apathy – on the contrary, increased anxiety.
Plan (P)
Diagnostics
Examination of the cardiovascular, endocrine and nervous systems. To exclude or confirm secondary arterial hypertension, it is necessary to examine blood on biochemical parameters such as electrolytes, glucose, cholesterol and lipid fractions. An orthostatic test is also needed to detect a significant decrease in systolic blood pressure when changing the body position from horizontal to vertical.
Therapeutic
Plant adaptogens (tinctures of lemongrass, aralia, ginseng) for daily consuming; cholinolytics, cerebroprotectors; nootropic drugs; antioxidants and vitamins (vitamins A, B, E intravenously); antidepressants and tranquilizers. With a sharp drop in blood pressure for the purpose of its rapid increase and stabilization – cardiotonic and vasoconstrictors, glucocorticoids, infusion of saline and colloidal solutions (Perez et al., 2020).
Educational: consultation on the day schedule and nutrition: discussion of healthy and active lifestyle, sports (walking, gymnastics), nutrition; various options for psychotherapy to eliminate stress and stress tolerance; training in self-massage of the cervical-collar zone; correction of the therapeutic physiological complex; training in procedures that strengthen blood vessels (contrast shower, hardening, massage). Recommendations for constant monitoring of blood pressure levels, regular monitoring by a cardiologist.
Consultation/Collaboration
Consultation of a neurologist on the diagnosis of diseases of the central and peripheral nervous system and pathologies of the musculoskeletal system. Checking reflexes, muscle strength, sensitivity, condition of the peripheral and autonomic nervous system, vestibular apparatus. Examination of the causes of dizziness for damage to the vestibular apparatus or blood flow through the vertebral arteries.
References
Knauber, J., König, A. K., Herion, T., Tabatabai, J., Kadmon, M., & Nikendei, C. (2018). Heidelberg Standard Examination: Final year students’ experiences with a handbook and instructional videos to improve medical competence in conducting physical examinations. GMS Journal for Medical Education, 35(3), 1-18.
Perez, T., Perez, R. L., & Roman, J. (2020). Conducting clinical research in the era of Covid-19. The American Journal of the Medical Sciences, 360(3), 213-215.