SOAP Note
S - 71-year-old female presents with nausea, near fainting episode, sweating, and clamminess while attempting to defecate. She has a history of constipation for 2-3 weeks, diabetes, and was recently diagnosed with a UTI, for which she was prescribed ciprofloxacin. She did not take her diabetes medication before arriving at the ED. O - Vital signs and physical examination are not provided. Laboratory results show WBC 17.9, seg neut absolute 14.8, glucose 286, sodium 134. X-ray indicates a moderate amount of stool throughout the large intestine, suggesting constipation. A - The patient's symptoms and laboratory results suggest a possible infection or sepsis, given the elevated WBC count, and a potential issue with blood sugar control, given the high glucose level. P - The plan would involve further evaluation of the patient's UTI, management of her diabetes, and addressing the constipation.
Differential Diagnosis
- Single Most Likely Diagnosis
- Vasovagal Syncope: The patient's symptoms of nausea, near fainting, sweating, and clamminess, especially triggered by attempting to defecate, are classic for vasovagal syncope. This condition is common and can be precipitated by straining during bowel movements.
- Other Likely Diagnoses
- Sepsis: Given the patient's recent diagnosis of UTI and the elevated WBC count, sepsis is a possible diagnosis, although the patient's current lack of symptoms makes it less likely.
- Hypoglycemia or Hyperglycemia: Although the patient's glucose is elevated, the fact that she did not take her diabetes medication before arriving and the symptoms could also suggest a glucose imbalance. However, the current glucose level is high, making hyperglycemia more likely than hypoglycemia.
- Dehydration: Especially in the context of constipation and possibly not drinking enough fluids, dehydration could contribute to the patient's symptoms.
- Do Not Miss Diagnoses
- Cardiac Ischemia or Arrhythmia: Although less likely given the specific trigger of straining during defecation, cardiac causes of syncope must always be considered, especially in older adults.
- Infectious Sepsis Leading to Septic Shock: While the patient seems stable now, the potential for sepsis to progress rapidly to septic shock, which is life-threatening, makes this a "do not miss" diagnosis.
- Rare Diagnoses
- Gastrointestinal Obstruction: Although the X-ray suggests constipation, a mechanical obstruction could also cause severe straining and subsequent syncope.
- Neurological Causes (e.g., Seizure, Transient Ischemic Attack): Less likely given the description, but possible causes of loss of consciousness or near-loss of consciousness that should be considered if other explanations are ruled out.