SBAP presentation format
Situation “This is a scheduled follow up visit for a longstanding patient of mine, she is coming in with a new symptom”
Background (introduce the clinical context, this allows your listener to better understand the CC)
“My patient is a generally well 75 year old, her past medical hx include:
Hypertension chronically uncontrolled despite 4 medications
Diabetes 2 diet controlled with A1c of 6.9
Intermittent benign positional vertigo for 5 years- triggered by movement in bed
Chronic low back pain”
it’s quite likely that your patient may have other medical conditions- CKD stage 3, hyperlipidemia, incidental thyroid nodule, knee arthritis, GERD, and constipation,…, But since these are not relevant to the context of her presentation today, listing them all run the risk of overwhelming and distracting your listener. (Certainly for new patients, do review all active and inactive medical conditions with your preceptors)
chief complaint/concern and hpi
“Patient’s chief concern today is new onset dizziness for 1-2 weeks, we scheduled this appointment a month ago after a new antihypertensive was added for a SBP of 170.
Since then, she notices intermittent non-vertiginous “lightheadedness”, dissimilar to prior positional vertigo. This new symptoms is described as a brief and diffuse weakness and unsteadiness, triggered mostly by standing up quickly. Notably last Sunday in church when she stood up, she had to grab the pew to avoid nearly falling over. She’s had about 3-4 similar episodes in the past month, each lasting no more than a minute. The symptom is not associated cp, sob, headache, or focal weakness. She also denies tinnitus, brpr or melena, or changes in home sugar testing results. She has not had to limit her daily activities, and is still able to climb 3 flights to her apartment daily. She is worried about falling, and wonders if the medication I prescribed last months may be contributing.
Aside from this, the patient has been very well, spends most of her afternoon watching her grandkids. Her chronic low back pain can only be felt with excessive house work. She performs glucose testing infrequently, and recalls most fasting values in the low 100s. Other ROS include chronic polyuria and nocturia up 3 times a night and mild insomnia occassionally.
(on a follow up visit you do not need to present the full family or social history, but you should highlight elements that may be relevant to the HPI)
Allergies and Medications (you can comment on changes)
Due to a history of cough with use of ace inhibitors, we have her on
Losartan 100mg daily
Atorvastatin 20mg daily ahs
Metformin 850mg bid
Metoprolol 50mg xl daily
Chlorthalidone 25mg daily qAM
Baby aspirin 81mg daily aAM
Acetaminophen 325mg tablet q 6 hrs prn pains
And we went up on her Amlodipine from 5 to 10mg daily last visit, she takes that in the morning
Exam and data (exam, data, list pertinents, both + and -)
On exam she appeared baseline, and ambulated with ease from waiting room chair to my office.
She is afebrile with nl respiratory rate, HR of 72, blood pressure was 120/70 down from 180/100 the last time. Orthostatic vital signs was without significant changes or triggering of symptoms.
Head and neck exam was notable for
reactive and symmetric pupils, moist mucosa, JVP was not elevated, and she has regular
rate and rhythm without murmurs/gallops. Her lungs were clear bilateraly by ascultationn.
Abdomen and back exam were nontender and benign. She has
FROM in knees shoulder without calf asymmetry, tenderness, nor pedal edema. Her
neurologic exam was notable for a narrow gait, negative Romberg and she tandem
walk with ease. Strength, reflexes,
finger to nose, and rapid alternating motions were unremarkable. Patient
declined a rectal exam and made clear that she did not recall any BRPR or
melena. Given the history of BPV a dix hallpike maneuver was performed and did not trigger vertigo
Labs from last week showed a hgba1c of 6.9 and her creatinine is stable at 1.3 with a slightly low potassium of 3.3. Her hemoglobin is normal and her LDL is 75.