Week 2

Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:

· Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the American Geriatrics Society Beers Criteria®, and consider alternative drugs if appropriate. Provide a review of systems.

· Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results? How would you interpret and address the results of the Mini-Mental State Examination (MMSE)?

· Assessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. Compare the diagnostic criteria for each, and explain what rules each differential in or out. Explain you critical thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.

· Plan: Provide a detailed treatment plan for the patient that addresses each diagnosis, as applicable. Include documentation of diagnostic studies that will be obtained, referrals to other healthcare providers, therapeutic interventions, education, disposition of the patient, caregiver support, and any planned follow-up visits. Provide a discussion of health promotion and disease prevention for the patient, taking into consideration patient factors, past medical history (PMH), and other risk factors. Finally, include a reflection statement on the case that describes insights or lessons learned.

· Provide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care. Follow APA 7th edition formatting. 

Case Study 1:

HPI: Ms. Peters is a 70-year-old female who is brought to your office by her son with reports of acute confusion (more than usual) and some agitation and restlessness. She has a known history of dementia, managed with Aricept 10 mg. daily. Her son, Jared, reports that 2 days ago she began to become more confused than usual and very easily agitated. He reports that yesterday, she couldn’t remember where she was in her own home. She had a doctor’s appointment 3 days ago and her HCTZ (hydrochlorothiazide) was increased to 50 mg. due to increased bp’s.

Ms. Peter’s last Mini-Mental State Exam (MMSE) score was 18/30. The assessment was repeated, and the score remained unchanged.

Ms. Peters and her son denies her having any falls or contributing traumas recently. She denies any changes in diet or routine regimens. No reported dysuria, no fever, nausea, or vomiting.

Note: Be sure to review the MMSE and how to interpret results ( Mental State Assessment Tests ). Make sure you document the patient’s score in your SOAP note document. Also review the Geriatric Depression Assessment ( Geriatric Depression Scale [GDS]).

Ms. Peters is a 70-year-old female who is alert but easily distracted, at times, during today’s clinical interview. Her eye contact is fair. Speech is clear and coherent but tangential at times. She makes no unusual motor movements and demonstrates no tics. She denies any visual or auditory hallucinations. She denies any suicidal thoughts or ideations. She is alert but disoriented to place and time. She denies any falls, denies any pain. Her son does say she has had some “stumbling” and balance issues but no reported falls.

All other Review of System and Physical Exam findings are negative other than stated.

Vital Signs: 98.1 120/64 HR-72 20

PMH: Hypertension, Diabetes, Osteoporosis, Chronic Allergic Rhinitis

Allergies: Atorvastatin

Medications:

· Multivitamin daily

· Losartan 50mg daily

· HCTZ 50mg daily

· Fish Oil 1 tablet daily

· Glyburide 5mg daily

· Metformin 500mg BID

· Donepezil 10mg daily

· Alendronate 70mg orally once a week

Social History: As stated in Case Study

ROS: As stated in Case study

Diagnostics/Assessments done:

1. CXR—no cardiopulmonary findings. WNL

2. CT head—diffuse Cerebral Atrophy

3. MMSE—Ms. Peters scored 18 out of 30 with primary deficits in orientation, registration, attention and calculation, and recall at a previous visit. At today’s visit, there is no change. The score suggests moderate dementia.

4. Hemoglobin A1C7.2%

5. Basic Metabolic Panel as shown below

TEST	RESULT	REFERENCE RANGE
GLUCOSE	90	65–99
SODIUM	130	135–146
POTASSIUM	3.4	3.5–5.3
CHLORIDE	104	98–110
CARBON DIOXIDE	29	19–30
CALCIUM	9.0	8.6–10.3
BUN	20	7–25
CREATININE	1.00	0.70–1.25
GLOMERULAR FILTRATION RATE (eGFR)	77	>or=60 mL/min/1.73m2

 

See below sample in yellow – Please do not make it equal as this below is from other student.

Patient Information:

Ms. P., 70-year-old, Female, White

S

Chief Complaint: Ms. Peters comes into the office with her son due to worsening confusion,

agitation, and restlessness.

History of Present Illness: Ms. Peters is a 70-year-old female who comes to the clinic

accompanied by her son, Jared, with reports of worsening confusion, some agitation, and

restlessness. Jared recalls that two days ago, her mom became more confused than usual and gets

agitated quickly. He states that her mom could not remember where she was at her home

yesterday. He added that her mom was seen by her doctor three days ago, and her HCTZ

(hydrochlorothiazide) was increased to 50 mg due to elevated blood pressure.

Current Medications:

Multivitamin daily

Losartan 50 mg 1 tablet daily

HCTZ 50 mg 1 tablet daily

Fish Oil 1 tablet daily

Glyburide 5 mg daily

Metformin 500 mg 1 tablet BID

Donepezil 10 mg 1 tablet daily

Alendronate 70 mg 1 tablet orally once a week

Allergies:

Atorvastatin

Past Medical History:

Dementia, Hypertension, Diabetes, Osteoporosis, Chronic Allergic Rhinitis

Immunizations: will obtain records

Social History: Lives at home with son. Denies tobacco and drug use.

Family History: No surgical history was reported.

Mental History: She has a history of dementia. She denies any visual or auditory

hallucinations. She denies any suicidal thoughts or ideation. Confusion more than usual 2 days

ago.

Violence History: She denies any issues about personal, home, community, and sexual violence.

Reproductive History: Postmenopausal

Review of Systems:

 General: No fever, chills, weakness, fatigue, or weight loss.

 Head: Denies any head injury or trauma.

 Eye: No blurry vision, double vision, or visual loss. No eye pain.

 Ears, Nose, Throat: No loss or changes in hearing, ringing, and discharges. Reports

balance issues and stumbling as noted by sob. No sneezing, congestion, runny nose, or

sore throat.

 Skin: No rash or itching.

 Cardiovascular: No chest pain, chest pressure or discomfort. No palpitations or leg

edema.

 Genitourinary: No dysuria, hematuria, polyuria, or nocturia. No breast changes, lumps,

and discharges. No history of breast cancer. Unknown mammogram history.

 Musculoskeletal: No muscle weakness, back pain, joint pain or stiffness. Denies any

falls. Some stumbling and balance issues as reported by her son.

 Neurological: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling

in the extremities. Memory changes reported by son. No history of stroke.

 Hematologic: No anemia, bleeding, or bruising. No blood transfusion and clotting

disorders reported.

 Lymphatics: No enlarged nodes or history of splenectomy.

 Pshychiatric: No history of depression or anxiety. Denies any visual or auditory

hallucinations. No suicidal thoughts or ideations. History of dementia.

 Endocrinologic: No sweating, cold, or heat intolerance. History of diabetes.

 Reproductive: Postmenopausal. No vaginal discharge.

 Allergies: No history of asthma, hives, eczema. Has history of chronic allergic rhinitis.

Reports allergy to Atorvastatin.

O

Physical Exam:

General: Alert but disoriented to time and place. Appropriately dressed, well-groomed and

appears well nourished. Speech is clear and coherent but easily distracted. Limited eye contact.

Vital Signs: BP: 120/64 HR: 72, regular R&R RR: 20, unlabored Temp: 98.1

HEENT:

Head: Normocephalic and no signs of injury or trauma. Intact facial sensation.

Eyes: Pupils equal, round, and reactive to light and accommodation. No redness or exudate. Eye

brows symmetrical.

Ears: Symmetrical. No swelling noted. No discharges. Tympanic membrane intact with no

erythema.

Nose: Symmetrical. No nasal deviation, nasal flaring polyps noted.

Throat: No erythema noted or exudates noted. Gag reflex intact.

Neck: Supple with full range of motion. No masses palpated. No tracheal deviation noted.

Respiratory: Clear lungs in all lung fields to auscultation with inspiration and expiration.

Bilateral chest with equal rise and fall on inspiration and expiration.

Cardiovascular: Heart rate 72, regular rate and rhythm, S1 and S2 noted. No murmurs, gallops,

and rubs. No bruits noted on abdominal aorta. Peripheral pulses intact. No edema noted.

Gastrointestinal: Abdomen soft, non-tender. Active bowel sounds in all quadrants.

Genitourinary: Bladder not distended.

Musculoskeletal: Fully weight bearing with some gait disturbances noted. Full ROM to upper

extremities, spine, hips, and lower extremities.

Integumentary: No significant rash or lesions observed. Skin color appropriate for age. Skin

warm to touch with skin turgor appropriate for age.

Neurologic: CN II – XII grossly intact. Noted some gait and balance disturbances. No unusual

movements or tics noted. Sensations on both arms and legs intact. Deep tendon reflex to lower

and upper extremities 2+.

Psychiatric: Mood and affect are appropriate but appears easily distracted.

Hematologic: No bruising or discoloration noted on exam.

Lymphatics: No enlarged lymph nodes palpated.

Diagnostic results:

1. CXR – No cardiopulmonary findings. Within normal limits.

2. CT Head – Diffuse cerebral atrophy.

3. MMSE – Score 18/30 with primary deficits in orientation, registration, attention, and

calculation, and recall at a previous visit. No changes in today’s visit. Score suggests

moderate dementia.

4. Labs – Hemoglobin A1C 7.2 %

5. Basic Metabolic Panel –

TEST RESULT REFERENGE RANGE

Glucose 90 65-99

Sodium 130 135-146

Potassium 3.4 3.5-5.3

Chloride 104 98-110

Carbon dioxide 29 19-30

Calcium 9.0 8.6-10.3

BUN 20 7-25

Creatinine 1.0 0.72-1.25

GFR 77 >or=60 ml/min/1.73m2

A

Differential diagnoses:

1. Dementia

Dementia is a clinical condition characterized with a cognitive decline from a previous level of

baseline function that interferes with activities of daily living (ADLs) (Kennedy-Malone, MartinPlank, & Duffy, 2019). Age is the most significant risk factor for dementia with prevalence rate

doubling every five years from the age of 65-85 (Dening and Aldridge, 2021). Ms. Peters showed

signs of confusion, worse than her baseline as indicated by her inability to recognize where she

was in her own home. She also has a history of dementia. Her MMSE score of 18/30 confirms

this primary diagnosis. dementia (Myrberg et al., 2020). The patient’s MMSE score suggest

moderate dementia. The MMSE is an 11-question tool that tests five areas of cognitive function:

orientation, registration, attention and calculation, recall and language (Laske & Stephens, 2018).

The perfect score is 30, with a score of 23 and lower indicates cognitive impairment (Laske &

Stephens, 2018). Advanced age, recent memory impairment, and changes in personality –

agitation and restlessness, are positive indicators of dementia.

2. Depression

Depression in elderly patients is a common disorder that affect their quality of life. Depression

contributes to adverse functional and social outcomes of the said population. Acute confusion

that was worse than baseline, agitation, and restlessness are positive indicators for depression.

Confusion or attention problems due to depression may also be attributed to AD, dementia, or

other brain disorders (National Institute on Aging, 2020); thus, it is crucial to rule out depression

to determine the primary diagnosis. The Geriatric Depression Scale is a self-rated questionnaire,

available in long form (30 items) and a short-form version (15 items) for diagnosing depression

with a cutoff score of eleven in the long form and seven points in the short form (Blackburn et

al., 2017). The reliability, however, decreases with increasing cognitive impairment. The said

screening tool will be included in the plan to rule out the diagnosis of depression.

3. Alzheimer’s Disease (AD)

AD is type of dementia that is characterized by a progressive loss of episodic memory and

cognitive function, which later causes deficiencies in language and visuospatial skills, and often

accompanied by behavioral disorders such as aggressiveness, apathy, and depression (Silva et al.,

2019). In assessing Mrs. Peters was reported to have stumbling and balance issues. This could be

an indication of a decline in visuospatial skills, indicating AD. Agitation and restlessness were

also noted with the patient which are positive indicators associated with AD. Current tests

performed does not confirm this diagnosis, thus, tests to check for biomarkers of cerebrospinal

fluid and positron emission 10 tomography in combination with several relatively new clinical

criteria can aid in confirming this diagnosis.

Plan

1. Order additional diagnostic studies.

a. Complete blood count and urinalysis can help rule out infections that may be causing

the changes in cognition.

b. Cerebrospinal fluid analysis will be ordered to rule out any specific infections affecting

the brain.

c. Toxicology screens for drug and alcohol use will also determine if the patient’s

behavior is related to controlled substances.

d. Magnetic Resonance Imaging (MRI) - can exclude potentially reversible dementia

causes such as hydrocephalus, subdural hematoma, stroke, and intra and extra-axial tumors

(Panegyres et al., 2016). The CT scan shows diffuse cerebral atrophy, but MRI has a higher

resolution that can detect subtle and anatomical and vascular changes.

e. Repeat Hemoglobin A1C in 3 months. Current result shows inadequate control of

blood sugar which may be contributing to the changes in the patient’s cognitive and functional

skills.

f. Perform Geriatric Depression Scale to determine depression.

2. Therapeutic interventions:

a. Continue Donezepil 10 mg tablet daily. Donezepil, a cholinesterase inhibitor, is the

recommended therapy for mild, moderate, or severe AD dementia (Panegyres et al., 2016).

b. Discontinue Glyburide component in the management of delirium, dementia, and AD.

The American Geriatrics Society Beers Criteria identifies medications to avoid in geriatric

patients. The Beers criteria strongly recommends glyburide to be avoided in older adults due to

higher risk of severe prolonged hypoglycemia (Al-Azayzih et al., 2019). Hypoglycemia can alter

a patient’s level of alertness. A fall in blood sugar can cause confusion, which was one of Mrs.

Peter’s presenting symptoms. Continue Metformin.

c. Continue the rest of her current medications to maintain control of blood pressure and

diabetes.

3. Refer patient for psychiatric evaluation can help determine if delirium, depression or other

mental health condition is contributing to the patient’s symptoms.

4. Education: Health promotion tasks.

a. Proper nutrition to control diabetes and high blood pressure to improve overall health

and reduce risk of worsening neurodegenerative disease.

b. Physical exercise to preserve strength and prevent loss of agility associated with age

and decrease neuropsychiatric symptoms. Less brain atrophy was noted in patients with AD who

had regular exercise (Panegyres et al., 2016).

c. Offer availability of influenza vaccine to patient.

d. Establish a safe environment. The patient may need assistance with activities of daily

living.

5. Follow up in one week for reevaluation. Perform a repeat MMSE to check for worsening of

dementia or AD. For worsening of symptoms or if new acute symptoms appear, take patient to

the emergency department for evaluation and treatment.

Reflection

Evaluating the case study helped a clinician analyzing the importance of obtaining an

adequate information in performing a SOAP note. There are some information missing in the

subjective and objective assessments that could assist in the creation of the assessment and plan.

A recent study discussed that disparities in the prevalence of dementia was not statistically

different for whites, blacks, and Hispanics (Chena & Zissimopoulosa, 2018); however, it is

important to note that the combination of socioeconomic 13 and cultural factors can affect the

compliance of patients in treatment plans. Will need to obtain immunization history and

information regarding the history of eye exam, colonoscopy, pap smear, and mammogram were

not supplied. Annual health screenings will aid in discovering diseases before they worsen,

especially with elderly patients who have greater risks due to comorbidities associated with

advanced age. Medication reminder is important to older patients as well. It is important to know

when the patient last took her medications to evaluate compliance to therapy. Literature showed

that poor adherence in medication regimen include patients with many comorbidities and

cognitive impairment (Smaje et al., 2018). The patient’s HgbA1c was elevated and patient

showed signs of confusion in her visit. Medication compliance can determine if the patient’s

symptoms were dosage related or a compliance issue to taking her diabetic and dementia

medications. The case study also did not say about Mrs. Peter’s family history. Although family

history is not necessary to develop AD and other dementias, it is important to note that that when

they run in families, genetic factors, environmental factors, or both may play a role (Panegyres et

al., 2016). Safety concerns for patients with dementia, AD, and delirium would include

wandering, fall risks, and inability to perform activities of daily living; thus, the importance of a

good support system is vital to ensure their safety.

Conclusion

Psychosocial disorders in the geriatric population is prevalent and proper assessment and

management are necessary to preserve their functional abilities. As advanced practice nurses, it is

important to obtain adequate information to be able to develop appropriate treatment plans,

including diagnostics and laboratory orders, for patients with psychosocial disorders. With the

anatomical changes related to advanced age, mental function changes along with it.

Understanding what happens during the aging process will allow the practitioner differentiate

between symptoms that are normal and those considered abnormal. For the older adult, physical

health, mental health, spiritually, environmental and social problems interact to complicate the

life and function of the older patient, caregiver, and family.

References

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10.18549/PharmPract.2019.2.1439

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https://doi.org/10.1001/jama.2019.4782

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