Case Study:
A 93-year-old Hispanic male is being evaluated for dizziness and near syncope in the long-term care facility. Past medical history includes myocardial infarction status post stents 20 years ago on aspirin and atorvastatin; history of stroke 3 years ago with hx of aspiration & left hemiplegia uses a walker for ambulation; diabetes with neuropathy and retinopathy no longer on medication due to weight loss (diet control- dysphagia & consistent carbohydrate diet with thicken liquids); insomnia on lorazepam as needed; and cognitive impairment. The family was unable to visit as frequently due to changes in visitation at the facility. No history of alcohol or illicit drug abuse but former tobacco abuse 50+ years. On Medicare and Medicaid insurance. The patient reports dizziness started today with position changes and denies changes in hearing or visual changes. Denies new numbness or tingling; always has numbness in feet. Denies headaches, chest pain, palpitations, and shortness of breath. Denies nausea and vomiting but has been having some loose stools. Today, the patient reports that when trying to go from bed to bedside commode, he felt like he was going to "blackout" but sat back down on the bed. Finally, he reports loneliness and continued issues with insomnia, naps frequently throughout the day and night but not for long periods. On exam, cachectic, very dry mucous membranes with poor dentition and hygiene. Tympanic membrane bilaterally pearly gray with visible landmarks and no effusions noted. Cranial nerves II to XII intact. No nystagmus. PERRLA. Heart regular rate and rhythm. Lungs clear to auscultation. Abdomen soft, non-tender, non-distended, normoactive bowel sounds in all 4 quadrants. No swelling on exam or JVD. Sacral pressure wound non-blanchable. Blood pressure sitting 114/67, then standing 90/54, heart rate sitting 89, then standing 104, respirations 18, oxygen 94% on room air, temporal temperature 98.3, height 5'8" weight 119 lbs.
With the above information, construct the patient's data into your final SOAP Note discussion board format (Celebrate and reflect on your growth!)
If there is missing information, include what you would ask or exam based on their presentation.
1. Make a plan to help rule in or out your differential diagnoses.
2. What might you notice during this visit that could lead you to suspect the possibility of elder mistreatment?
3. What other factors might you consider important in evaluating the risk of elder mistreatment?