Assessment and Plan   (same case discussed in Background page):

The assessment or summary statement line is a critical step in diagnosing and cognitively processing the case. This is a 1-3 sentences concise summary that highlight only important findings from history, physical exam, and testing. The intention is to review key discoveries by converting raw data into generalizable medical concepts.  The clinical terminology used here will help others to trigger recall and prioritize potential differential diagnoses.


“In summary, this is a 75 year old female with diabetes and longstanding difficult to control hypertension presenting with orthostatic dizziness after a recent medication change.  Aside from an improvement in her blood pressure from the last visit, her exam did not demonstrate orthostatic changes nor neurologic findings. Labs showed good diabetes control with a slightly low potassium.”

 

Following the summary line, articulate each “problem” encountered in the case, discuss potential differentials and your next steps (the Plan follows the discussion of each problem). 

 

Problem #1

Dizziness- has a wide variety of causes, in this elderly hypertensive patient, potential causes to consider include orthostatic sensation with the recently intensified anti-hypertensive regimen; new cardiac ischemia or failure; a cerebrovascular event, and less likely in this case disequilibrium due to arthritis related gait disorder or an anemia due to aspirin related GI bleed.  Based on the recurrent and predictably triggered nature of the symptom with standing up, the preserved functional status, the benign physical exam notable only for significantly lowered blood pressure; I am pretty certain the cause of this dizziness relates to recent medication change.              

Plan- Given the good response of blood pressure to the higher calcium channel blockade, will stop chlorthalidone and keep amlodipine at 10mg.  This may even help with her polyuria.

 

Problem #2

Hypokalemia- the differential include GI or renal loss, as well as hypertension inducing hormonal conditions like Conn’s syndrome.  Since it is new, it is most likely chlorthalidone related potassium depletion.

Plan- d/c chlorthalidone and repeat her potassium level at my next visit. If it remains low we will do further evaluation.

 

Problem #3

Diabetes-  very well controlled with no low fsg results.  Her CKD does not preclude continual use of metformin. 

Plan- given the stability of her good control, will repeat the hgba1c in 6 months.  She is due for her annual eye exam.

 

Problem #4 (the penultimate problem of each outpatient visit is preventive care, a patient centered recommendation of vaccines, screening tests, or behavioral counseling)

Health Maintenance  

-Discussed risk and benefit of shingles vaccine with patient again, she is still not sure. Patient is considering making her daughter her health care proxy, forms have been given. She is due for a repeat of her bone density next year.

 

Problem #5  (Lastly define when you want the patient back for follow up)

Follow up  Will schedule a return to follow up her symptoms and her blood pressure and labs in 2 months.