ASSIGNMENT

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.

Reminder Links to an external site.: The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Center provides an example of those required elements (available at http://writingcenter.waldenu.edu/57.htm). All papers submitted must use this formatting.
To prepare:

Review the case study you chose. Reflect on the way the patient presented in the case, including whether the patient might be presenting with dementia, delirium, or depression.
Reflect on the patient’s symptoms and aspects of disorders that may be present. What distinct symptoms or factors would lead you to a diagnosis of dementia, delirium, or depression?
Consider how you might assess, perform diagnostic tests, and recommend medications to treat patients presenting with the symptoms in the case.

Case Study:
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 Weight: BMI: (formulate these from your past experiences). Note whether the BMI falls within normal, overweight, obese, etc. There is an easy app to use you can google to plug in the Wt and Ht and it will calculate the BMI for you.
*BMI is required

PMH: Hypertension, Diabetes, Osteoporosis, Chronic Allergic Rhinitis
Allergies: Atorvastatin, rash
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 A1C 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

Upon reviewing her labs – what is your diagnosis for Ms. Peters? Look carefully at the labs, her PMH, and current symptoms. What is your treatment plan? Remember that she is already being treated for dementia. Part of making a correct diagnosis is being a detective – do not miss the simple diagnosis, nor the common symptoms. Your primary diagnosis should be one of the differential diagnoses. Include a rationale of why you ruled in – or ruled out the ddx and chose the primary diagnosis. (The standard is at least 3 ddx, with one of these being your primary dx).