SBAP presentation format
Situation “This is a follow up visit for a patient of mine, she is coming in with new dizziness”
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
Chronic kidney disease stage 3B
Intermittent benign positional vertigo for 5 years- triggered by movement in bed”
it’s quite likely at this age that your patient may have other active medical conditions- GERD, hyperlipidemia, knee and back arthritis, and chronic constipation, but since those are not relevant to her presenting symptoms and they should not be mentioned during the presentation as it may overwhelm your listeners
(back to cc and HPI)
“Patient’s chief concern today is acute dizziness for 1-2 weeks, I had previously scheduled this appointment a month ago to after we added a new antihypertensive for a SBP of 170.
She describes the dizziness as non-vertiginous, dissimilar to her positional vertigo. This time a weakness and a brief sensation of unsteadiness. It is only noticed when she is upright. Last Sunday in church when she stood up quickly and almost fell. There is no other symptoms, pains, or focal weakness. The sensation scares her but does not limit her daily activities; patient is still able to walk up 3 flights to her apartment without difficulties. She is concerned that the medication we prescribed last months ago may be contributing. Despite that she has been very compliant with it. She denies presbycusis, tinnitus, headache, and brpr or melena. Her fsg have not shown low values during these episodes.
Aside from this sensation, she has been well, spends most of her afternoon watching her grandkids. Her chronic low back pain is only worse when the weather is bad but she remains active w adl and iadl. She performs glucose home testing infrequently but all of her fasting values have been in the low 100s. Other ROS include frequent urination causing her to get up 3 times a night, occasional chronic arthritis pain of the L knee, and mild insomnia which are chronic.
(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)
(now list allergies and medications, comment on new 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 time, she takes that in the morning
(exam, data, list only pertinents, both + and -)
On exam she appears to be well and ambulated easily and quickly in the hallway with no distress
She is afebrile with nl respiratory rate, HR is 72, her blood pressure was 120/70 down from 180/100 the last time, she had no orthostatic changes or symptoms on my check.
The rest of the exam is
unremarkable, she was regular heart rate with no murmur, clear lungs, a benign
abdomen, and no calf tenderness or pedal edema. Her neurologic exam did not
demonstrate any focal weakness, cerebellar signs, and she was able to tandem
walk normally without any dizziness.
Given the history of BPV a dix hallpike maneuver was performed and did not elicit any
vertigo or nystagmus.
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.