Nursing

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.

ANSWER

SOAP Note

Patient Information:

Initials: M.W,              Age 67,           Sex: Female,   Race: African American

Subjective

CC: “My mother is demonstrating increased forgetfulness and is unable to easily remember most recent things; however she can easily remember historical moments or events”

HPI: M.W is a presentable a 67-year-old African American female accompanied to the clinic by her daughter complaining of her forgetfulness. M.W has been living with her daughter for four years who noticed that M.W kept asking the same questions even after they have been answered. According to the daughter M.W at some got lost in Walmart. The daughter also reports that M.W experiences problems in “finding the right words” in a discussion, and changes to a different dialogue. M.W also “laughs off things” when she forgets important appointments and becomes critical of people who point out these things to her. M.W denies any visual or auditory, denies any suicidal thoughts or ideations, and denies any falls or pain.

Current Medication:

Amlodipine 10mg daily for HTN, HCTZ 12.5mg daily to manage HTN, Multivitamin daily for dietary supplement, Atorvastatin 40mg daily to manage hyperlipidemia and Alendronate 70mg orally once a week to manage osteoporosis.

Allergies: Penicillin (rush) and Lisinopril (cough).

PMHx: Hypertension, Hyperlipidemia, and Osteoporosis

Social hx: M.W lost her husband of 57 years four years ago. M.W has been living with daughter for the last four years. M.W was a teacher before retirement. The daughter describes M.W as a normally quite astute according to her daughter.

Surgical Hx: Denies any surgical history.

Mental Hx: Denies any suicidal thoughts or ideations.

Review of Systems:

General/Physical: The patient is conscious, watchful and oriented, friendly and very compliant. Denies any suicidal thoughts or ideations, denies auditory or visual hallucinations, and M.W maintains a fair eye contact.

HEENT: M.W denies headache, denies any loss of vision, double vision or blurred vision. M.W denies sneezing, runny nose, congestion or sore throat.

SKIN: M.W denies any rash or itching.

CARDIOVASCULAR: M.W denies any chest pain. M.W has no edema or palpitations.

RESPIRATORY: M.W denies cough, sputum and SOB.

GASTROINTESTINAL: M.W denies abdominal discomfort. M.W denies vomiting  or nausea or alterations of bowel movement.

NEUROLOGICAL: M.W is negative for paralysis, headache, dizziness, ataxia or syncope. M.W denies changes in bladder control.

GENITOURINARY: MW denies hematuria or dysuria.

MUSCULOSKELETAL: M.W denies joint pain, back pain, facial droop or focal weakness.

LYMPHATICS: M.W has no enlarged nodes and denies splenectomy.

PSYCHIATRIC: M.W denies any history of depression or anxiety.

HEMATOLOGIC: M.W denies history of anemia, bleeding or bruising.

Objective

General: M.W is alert, compliant with today’s clinical consultation. M.W eye contact is fair. M.W is oriented to person, partly angled to place but is confused to time and place. M.W does not make any unusual motor movements and exhibits no tics. M.W’s Speech is clear and clear yet tangential in some instances.

Neurological: M.W can mention her name and place with clear speech. M.W on the mini-mental status examination scored 18 out of 30 with main scarcities in registration, orientation, calculation, attention and recall. The findings indicate mild dementia. Gait is coordinated and appropriate with no signs of tics.

Musculoskeletal: Some age-related atrophy.

Diagnostic results: CXR- no cardiopulmonary findings.

CT head- diffuse Cerebral Atrophy

Mini-mental used to assess cognitive impairments (Athilingam et al., 2015). M.W scored 18 out of 30 which indicate moderate dementia. It is prevalent for a person with Alzheimer’s disease to undergo a reduction of 2 to 4 points every 12 months (Alz.org, 2020).

Assessment:

            The symptoms most relevant to this patient include increased forgetfulness, disorientation and the low MMSE scores. The differential diagnoses include Alzheimer’s disease, vascular dementia, and geriatric depression. Unlikely diagnoses for the patient include Lewy body disease, vitamin deficiencies, and viral infections. The CT scans of the head indicating brain lesions are consistent with dementia diagnosis. Absence of lesions in a specific distribution of blood vessels excludes vascular dementia as the cause of the patient’s memory loss. Besides, the patients is losing her memory in a slow manner which rules out Lewy body disease while vitamin deficiencies may contribute to her current condition (patients with dementia have poor eating habits).

Primary Diagnosis: Early-onset Alzheimer’s

Three Differential Diagnoses

• Early-onset Alzheimer’s: The most prevalent type of dementia is Alzheimer’s. The significant risk elements are age, particularly for people above the age of 65. Alzheimer’s is a continuous condition that gradually worsens the cognitive ability of the patient and derails the routine activities. There is no mention of family history of dementia for M.W, however, the patients low MMES score makes Alzheimer’s a possible diagnosis. A MRI exam should be done to evaluate structural alterations (Wolk & Dickerson, 2018).
• Vascular dementia: A condition resulting from a cerebrovascular sickness that inhibits the blood flow leading to cognitive damage (Smith & Wright, 2018). The risk elements comprise diabetes, HTN, age, hyperlipidemia, smoking and CVDs (Smith & Wright, 2018). Symptoms of Vascular dementia can at times resemble those of Alzheimer’s hence a mute cerebrovascular sickness takes place devoid of the patient’s awareness (Smith & Wright, 2018). Imaging findings are needed to evaluate for existing or previous cerebrovascular illness (Smith & Wright, 2018).
• Geriatric Depression: Is a form of emotional and mental condition in older adults; however lasting depression is not a common sign of aging (Masse-Sibille et al., 2018). Geriatric depression does not meet full criteria of major depression however can lead to major depression if left untreated. Common risk factors include deaths of friends and loved ones, transitioning from work to retirement, limited mobility and chronic conditions.

Plan

Documentation of diagnostic studies to be acquired:

Imaging findings: CT head which identified diffuse cerebral atrophy

An MRI evaluation as the imaging could identify lesions that were not seen in the CT scan.

Alternative medications: M.W can be considered for a different diuretic with less hypokalemic effect to manage blood pressure and can be suggested another medication for hyperlipidemia (PCSK-9 inhibitors) (American Geriatrics Society, 2015).

Referrals: Dementia counselors and occupational therapists who can help maintain cognitive function.

Therapeutic interventions

Education: Teaching lifestyle changes, engaging in physical exercise, socializing regularly, maintaining healthy diet with low calories and to maintain cognitive function, and challenging her brain regularly (Mendiola-Precoma, 2016).

Patient Disposition: M.W’s beliefs and hopes concerning personal care options in the future would assist in guiding her disposition.

Reflection

            I acquired the understanding into the value of diagnosing a client with cognitive dysfunction immediately after the symptoms have developed. Understanding the nature of a client’s sickness enables the patient, friends and family members to comprehend what is happening and what to expect. I also learned the causes of forgetfulness such as dementia, mild cognitive impairment, delirium, psychiatric issues and alcohol addiction.

Reference

American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. (2015). Journal of the American Geriatrics Society, 63(11), 2227–2246. https://doi.org/10.1111/jgs.13702

Athilingam, P., Visovsky, C., Elliott, A. F., & Rogal, P. J. (2015). Cognitive Screening in Persons With Chronic Diseases in Primary Care. American Journal of Alzheimer’s Disease & Other Dementiasr, 30(6), 547–558. https://doi.org/10.1177/1533317515577127

Masse-Sibille, C., Djamila, B., Julie, G., Emmanuel, H., Pierre, V., & Gilles, C. (2018). Predictors of Response and Remission to Antidepressants in Geriatric Depression: A Systematic Review. Journal of Geriatric Psychiatry and Neurology, 31(6), 283–302. https://doi.org/10.1177/0891988718807099

Mendiola-Precoma, J., Berumen, L. C., Padilla, K., & Garcia-Alcocer, G. (2016). Therapies for Prevention and Treatment of Alzheimer’s Disease. BioMed Research International, 2016, 1–17. https://doi.org/10.1155/2016/2589276

Smith, E., & Wright, M. D. C. (2018). Etiology, clinical manifestations, and diagnosis of vascular dementia. https://www.uptodate.com/contents/etiology-clinical-manifestations-and-diagnosis-of-vascular-dementia?search=Vascular+dementia&source=search_result&selectedTitle=1~60&usage_type=default&display_rank=1#H337964271.

Yoon, P., Ooi, C., & How, C. (2018). Approach to the forgetful patient. Singapore Medical Journal, 59(3), 121–125. https://doi.org/10.11622/smedj.2018026