SBAP presentation format

Background   (following up on case 1 from the Situation page):

(introduce the patient, this allows your listener to better understand upcoming CC and history)

 

“My patient is a generally well 75 year old, her past medical hx include:

Hypertension not well controlled for years despite several medications

Diabetes well controlled on metformin

Chronic kidney disease stage 3

Hyperlipidemia

Chronic low back pain and knee pain”

 

(now the cc and HPI)

“Patient’s chief concern today is dizziness for several weeks, I had previously scheduled this appointment 2 months ago to follow up her blood pressure after we changed her medications.

 She describes her dizziness as a general weakness, lightheadedness, a sensation of unsteadiness. It’s been present for at least a month, and is only noticed when she is upright. One time when she stood up quickly she almost fell. There is no other symptoms or focal weakness.  It does not limit her daily activities, and she is still able to walk up 3 flights to her apartment without difficulties. She has a longstanding history of feeling dizzy at times, but she reports this symptom is more severe than her more chronic  sensation of dizziness. She is concerned that the medication we prescribed 2 months ago may be contributing. Despite that she has been very compliant with it. She denies vertigo, hearing difficulty, tinnitus, headache, bright red blood per rectum or melena, shortness of breath, chest pain, or difficulty walking.

Other than that she has been doing well, with good energy, and has been watching her grandkids. She notes no problems with her home glucometers checks with fasting values between 100-150. Her chronic low back pain is only worse when the weather is bad but she remains active w adl and iadl. Her 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 both chronic.  

(on a follow up visit you do not need to present the full family or social history, but you should highlight components relevant to history)

(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

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.  I know she did not have vertigo, but a dix hallpike maneuver was attempted and did not trigger symptoms or nystagmus.
Labs from last week showed a hgba1c of 7.0 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.