SUBJECTIVE
CC: “I am lightheaded when I sit up x 3 days.”
HPI: P.R. is 84-year-old women with a PMH of HTN, CAD s/p PCI, Hypothyroidism and Parkinson’s Disease. Patient is seen at the rehab; she is complaining that she is lightheaded when she sits up for the last 3 days. She feels like she is about to pass out during those events. Patient is at the rehab post left heart catheterization, she was stabilized and sent for rehab. During PT, she tries to get out of bed, but becomes symptomatic and does not want to move. It was noted by the physical therapist that patient’s BP from laying 122/82 to standing 89/54. Patient becomes diaphoretic, lightheaded, and nauseous. One she lays back down, BP returns to baseline and symptoms resolve. Patient denied any chest pain or SOB.
PMH:
Hypothyroidism: Diagnosed at age 65
CAD: PCI 2 weeks ago to RCA
Parkinson’s disease: Diagnosed at age 66, follows with Neurologist every 4 months
HTN: Diagnosed at age 52, follows with cardiologist every 4 months
Surgery: B/L Hip replacement, right 2012, left 2019, LHC 2 weeks ago, hysterectomy at age 45
Last Hospitalizations: as listed above
Health immunizations: Up to date with COVID and flu vaccines, up to date on childhood vaccines
Medications:
-Amlodipine 5mg PO QHS
-Carbidopa/levodopa 25mg/100mg TID
-Aspirin 81mg PO QD
-Brillinta 90mg PO BID
-Losartan 100 mg 1 tab PO QAM
– Synthroid 112 mcg 1 tab PO QAM
Allergies:
-Denies drug, environmental, pet allergies
-Admits to allergies to Latex
Family History:
-Father (Deceased, age 88): HLD, CHF, MI/CAD, Prostate CA
-Mother (Deceased, age 89) HLD, Breast CA,
-Brother (Deceased, age 77) MI/CAD, HTN, CHF
Social History:
Occupation: Retired from school district
Education: BSN
Living situation: husband deceased, lives home alone. Feel safe at home.
Diet: Reports healthy diet at home. Breakfast: eggs, coffee Lunch: Salad or sandwich. Dinner: Chicken or steak with vegetables and rice. (Currently in rehab and following diet restriction)
Substance/tobacco abuse: Denies tobacco, drug, and illicit drug use
Physical activity: none reported
Sleep: Denies any sleeping disturbances. Sleeps 5-6 hours per night.
ROS
General: Admits to diaphoresis during episode. Denies insomnia, weakness, fatigue.
HEENT: Admits to using glasses when reading. Denies head trauma tearing, blurriness, tinnitus, epistaxis, rhinitis.
Respiratory: Denies shortness of breath, cough, wheezing, dyspnea, respiratory infections.
Cardiovascular: Denies chest pain, chest tightness, palpitations, tachycardia, heart murmurs, edema.
GI: Admits too nausea during event. Denies vomiting, diarrhea, constipation, abdominal pain. LBM: 2 days ago
Neuro: Admits to lightheadedness during event. Denies headache, light sensitivity, changes in LOC, weakness, memory problems.
OBJECTIVE
Vitals: • Temp: 97.4°F • BP: laying 122/82 to sitting 89/54. • HR: 87 BPM • RR: 19 BPM• O2 Sat: 98% on room air• Height 5 feet 2 inches
Weight: 144 pounds • BMI: 26.3 kg/m2
Orthostatic static vitals: lying: 126/84 sitting: 100/64, standing: 84/58
Labs/other tests
-recent CBC/CMP done 2 days ago, unremarkable
PE
General: P.R. is alert and oriented, lying-in bed, NAD. She is well-nourished, well-developed, and dressed appropriately with good hygiene.
HEENT: Head appears normocephalic and atraumatic. Facial features symmetric. No visible abnormal findings noted in the right or left fundus. Disc margins sharp bilaterally. Auditory canals appear pink, TM is intact and pearly gray. No discharge, polyps, foreign bodies, lesions, deviated/perforated septum visible.
Respiratory: Chest is symmetric bilaterally with no lesions or deformities. Chest rise is symmetrical with respirations. Lungs are clear with auscultation in all lung fields with no cough, wheezing, crackles, rhonchi, or rales.
Cardiovascular: Heart rate is regular, S1 and S2 present with no murmurs, gallops, rubs. No bruit in the bilateral carotids on auscultation. Carotid arteries +2 with no thrill on palpation.
GI: Bowel sounds present and normoactive in all 4 quadrants. Abdomen soft and nontender, no guarding noted.
Neuro: All CNs intact. Sensation to pain, touch, proprioception is normal. DTRs 2+ and equal B/L in the upper and lower extremities.
ASSESSMENT:
-Working diagnosis: Orthostatic Hypotension (I95.1) P.R. is an 84-year-old female who has been at the rehab and feeling lightheaded with PT. BPs are dropping more then 20mm Hg systolic and 10mm Hg from different positions from lying to standing. Patient is symptomatic and improves once back in lying position.
-Hypothyroidism (E03.9) Well-controlled, check in endocrinology office 2 months ago. On Synthroid 112 mcg.
-HTN (I10) On Amlodipine 5mg QD PO and Losartan 100mg PO QD. Controlled while in rehab.
-Parkinson’s Disease (G20): controlled and follows with Neurologist every 3 months, takes Carbidopa/levodopa 25mg/100mg TID
-CAD s/p PCI to RCA: On ASA 81 mg and Brilinta 90mg BID
PLAN:
Orthostatic Hypotension (I95.1)
-stay hydrated
-Continue healthy, low sodium diet
-Compression stockings or TEDS recommended
-recommend abdominal binder
-Educate patient to change positions slowly and not getting out of bed too quick to prevent falls
-can consider decreasing BP medications including Losartan to 50mg QD to allow BP to run on the higher side
-continue to monitor volume status and CMP for any signs of dehydration, infection
-Recommend raising head of bed minimum of 30 degrees when lying in bed
-Educate patient that Parkinson’s disease can contribute to orthostatic hypotension
Hypothyroidism (E03.9)
–Continue Synthroid 112 mcg
-Continue to follow with endocrinologist and annual labs
HTN (I10)
-Decrease Losartan to 50mg QD and monitor BP per Rehab protocol
-continue with cardiology appointments
Parkinson’s Disease (G20):
-Continue Carbidopa/levodopa 25mg/100mg TID
-Continue to follow with Neurologist
CAD s/p PCI to RCA:
–Continue ASA 81 mg and Brilinta 90mg BID, cannot stop DAPT due to recent stent
-continue with cardiology recommendations regarding DAPT
-Monitor CBC and monitor for any signs of bleeding
