Can you provide a SOAP note for an elderly female patient at a 2‑week follow‑up of her medication regimen who complains of increased dizziness, has a history of falls, subclavian artery stenosis, seizure disorder, type 2 non‑ST‑segment elevation myocardial infarction, and reports back pain and numbness to the bilateral lower extremities?

SOAP Note: Elderly Female with Increased Dizziness, Falls History, and Multiple Comorbidities

SUBJECTIVE

Chief Complaint: Increased dizziness at 2-week medication follow-up

History of Present Illness:

• Increased dizziness since last visit (quantify: frequency, duration, relationship to position changes, exertion)
• Critical screening questions:
  • Timing: Does dizziness occur with standing (orthostatic), with arm use/exertion (subclavian steal), or at rest?
  • Associated symptoms: Presyncope, visual changes, arm fatigue, chest discomfort, palpitations
  • Fall circumstances: Any recent falls? Injuries sustained?

Past Medical History:

• Subclavian artery stenosis (side? severity? prior intervention?)
• Type 2 NSTEMI (date? revascularization performed? CABG with LIMA graft?)
• Seizure disorder (controlled? recent seizures?)
• History of falls
• Back pain with bilateral lower extremity numbness (new vs. chronic? progressive? associated weakness?)

Current Medications: [Document complete list with doses, frequency, start dates]

OBJECTIVE

Vital Signs:

• Orthostatic vital signs (MANDATORY): Supine BP/HR → Standing BP/HR at 1 and 3 minutes
  • Orthostatic hypotension defined as: ≥20 mmHg systolic OR ≥10 mmHg diastolic drop 1
• Bilateral arm blood pressures (>15 mmHg difference suggests subclavian stenosis) 2, 3, 4
• Oxygen saturation

Physical Examination:

• Cardiovascular: Heart sounds, peripheral pulses (radial pulse quality bilaterally, subclavian/carotid bruits)
• Neurological: Cranial nerves, strength/sensation in bilateral lower extremities (dermatomal pattern?), gait assessment, Romberg test
• Musculoskeletal: Spine tenderness, straight leg raise

Cognitive Assessment: Brief screen (orientation, recall) to assess for medication-related cognitive impairment

ASSESSMENT

Primary Concern: Medication-Related Dizziness with High Fall Risk

This elderly patient with polypharmacy, subclavian stenosis, and NSTEMI history requires immediate medication reconciliation and deprescribing to reduce fall risk and prevent serious injury or death. 5, 6, 7

Critical Differential Diagnoses to Rule Out:

1. Orthostatic Hypotension (Most Likely):

   • Fall-Risk Increasing Drugs (FRIDs) assessment is MANDATORY 8, 9
   • High-risk medications causing orthostasis/dizziness:
     • Antihypertensives (especially diuretics, alpha-blockers, beta-blockers)
     • Psychotropics (benzodiazepines, antidepressants, antipsychotics, antiepileptics)
     • Opioids for back pain
     • Anticholinergics (antihistamines, overactive bladder agents, muscle relaxants) 6
   • Action: If orthostatic hypotension confirmed, reduce/discontinue offending agents 1, 6

2. Coronary-Subclavian Steal Syndrome (CSSS):

   • If patient has prior CABG with LIMA graft: Subclavian stenosis can cause myocardial ischemia AND vertebrobasilar insufficiency 2, 3, 4
   • Red flags: Dizziness with arm exertion, arm claudication, >15 mmHg BP difference between arms, chest discomfort
   • Action: Urgent vascular surgery/interventional cardiology referral if suspected

3. Vertebrobasilar Insufficiency:

   • Exercise-induced dizziness from Grade III subclavian steal 4
   • Action: Duplex ultrasonography to assess vertebral artery flow

4. Spinal Cord Compression:

   • Back pain + bilateral lower extremity numbness = potential cauda equina/cord compression
   • Red flags: Saddle anesthesia, bowel/bladder dysfunction, progressive weakness
   • Action: Urgent MRI spine if red flags present

5. Post-NSTEMI Complications:

   • Arrhythmia, heart failure, recurrent ischemia
   • Action: ECG, consider echocardiogram if not recent

PLAN

Immediate Actions (Today):

1. Medication Reconciliation and Deprescribing 5, 6, 7

   STOP or REDUCE these high-risk medications:

   • Psychotropics/Benzodiazepines: Taper and discontinue if possible (strongest fall association) 8
   • Strong anticholinergics: Diphenhydramine, cyclobenzaprine, oxybutynin (cause cognitive impairment, falls) 6
   • Antihypertensives causing orthostasis: Reduce doses if BP allows; avoid multiple agents
   • Opioids: Minimize or switch to non-sedating alternatives for back pain
   • Antiepileptics: Review necessity; ensure therapeutic levels if required for seizure control

   CONTINUE (Class I recommendations for post-NSTEMI): 10, 11

   • Aspirin 81 mg daily (indefinitely)
   • P2Y12 inhibitor (clopidogrel/ticagrelor/prasugrel) if <12 months post-stent
   • Beta-blocker (unless causing symptomatic bradycardia/hypotension)
   • ACE inhibitor/ARB if LVEF ≤40% or heart failure
   • High-intensity statin

   Adjust if orthostatic:

   • Hold morning antihypertensive if systolic BP <120 mmHg or symptomatic orthostasis
   • Consider switching beta-blocker to cardioselective agent at lower dose

2. Diagnostic Workup:

   • ECG (rule out arrhythmia, ischemia)
   • Bilateral arm BP measurements (subclavian stenosis screening)
   • Basic metabolic panel (electrolytes, renal function affecting drug clearance)
   • If >15 mmHg arm BP difference OR arm-exertion dizziness: Duplex ultrasound bilateral subclavian/vertebral arteries 4
   • If neurological deficits/red flags: Urgent MRI lumbar spine

3. Fall Prevention:

   • Physical therapy referral for gait/balance training
   • Home safety evaluation
   • Educate: Rise slowly from sitting/lying, avoid sudden head turns
   • Consider assistive device if gait instability

Follow-Up:

• 1 week: Reassess symptoms after medication changes, repeat orthostatic vitals
• Vascular surgery consultation if subclavian steal confirmed
• Neurosurgery/spine if cord compression identified
• Cardiology if recurrent ischemic symptoms (sublingual nitroglycerin prescribed, instructed to call 911 if chest pain >5 minutes despite nitroglycerin) 10, 11

Patient Education:

Provided verbal and written instructions: 10, 11

• Medication changes and rationale
• Fall precautions
• Cardiac symptoms: Call 911 if chest pain/pressure, severe shortness of breath, or dizziness with chest discomfort
• Neurological red flags: Seek emergency care for sudden weakness, loss of bowel/bladder control, or worsening numbness

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Key Clinical Pitfall: In elderly patients with polypharmacy and dizziness, the reflex is often to add medications (antivertigo agents, antiemetics). The correct approach is aggressive deprescribing of FRIDs, particularly psychotropics and anticholinergics, which have the strongest evidence for causing falls and cognitive decline 5, 6, 8. However, do not discontinue proven mortality-reducing medications (aspirin, P2Y12 inhibitors, beta-blockers, ACE inhibitors, statins) in post-NSTEMI patients unless absolutely contraindicated 10, 11.

Special consideration for subclavian stenosis: This patient's subclavian stenosis could be causing both vertebrobasilar insufficiency (dizziness) AND myocardial ischemia if she has a LIMA graft—a rare but critical diagnosis requiring urgent revascularization 2, 3.