Comprehensive SOAP Note
Name
Academic Institution
Comprehensive SOAP
Patient Initials: ___Ms. P____ Age: ___70____ Gender: ___F____
SUBJECTIVE DATA:
Chief Complaint (CC): Acute confusion, agitation and restlessness.
History of Present Illness (HPI): Ms. Peter is a 70-year old female brought to the healthcare facility by the son. Her son indicates that the mother has acute confusion, agitation and restlessness. The son indicates that the symptoms started two days ago. The son related the condition with a doctor’s visit three days ago. Her HCTZ (hydrochlorothiazide)’s dose was increased to 50mg due to high blood pressure. She is confused and agitated and could not remember her home yesterday. The patient has been taking medication, including Aricept 10mg, to control dementia. The patient denies lifestyle changes. He has no significant family history of high blood pressure or dementia. The patient’s last Mini-Mental State Exam (MMSE) is 18 out of 30.
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
Allergies: Atorvastatin
Past Medical History (PMH): Dementia and high blood pressure,
Past Surgical History (PSH): She has no surgical history.
Sexual/Reproductive History: Heterosexual but not sexually active.
Personal/Social History: No smoking or history of taking ETOH.
Immunization History: All immunizations are up to date.
Significant Family History: The client’s information does not show significant family history and the health condition of the parents
Lifestyle: The son does not provide information about the mother.
Review of Systems:
General: She is alert but easily distracted during the session. 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. No reported dysuria, no fever, nausea, or vomiting.
HEENT: She has no hearing challenges or vision impairment. The last eye examination details are not available. No discharge in the ears or infection. Her smell is unblemished. The patient has no running nose as well as nasal congestion. Oral mucosa is intact and clean. Information about a recent detailed examination is not available. Swallows food comfortably and no dental infections.
Neck: Diffuse involvement of the scalp.
Breasts: No rashes.
Respiratory: No breathing challenges or a history of trauma.
Cardiovascular/Peripheral Vascular: No challenges in the chest, dyspnea, edema or palpitations.
Gastrointestinal: No reflux, abdominal pain, nausea, or abnormal bowel sounds,
Genitourinary: Normal urine patterns.
Musculoskeletal: She has no history of gout.
Psychiatric: No suicidal ideation, depression or sleep disorders.
Neurological: Has stumbling and balance issues, but no reported falls.
Skin: No bruises, wounds, itching, bleeding, or rashes.
Hematologic: She has no history of blood disorder.
Endocrine: Has no endocrine disorder.
Allergic/Immunologic: Atorvastatin.
OBJECTIVE DATA
Physical Exam:
Vital signs: 98.1 120/64 HR-72 20
General: A&O *3 NAD and dressed for the visit. She is alert but disoriented to place and time. HEENT: Plaque involvement diffusely on the central face. Diffuse involvement of his scalp.
Neck: Carotids no bruit.
Chest/Lungs: CTA AP&L.
Heart/Peripheral Vascular: RRR without a murmur, rub, gallop, pulses +2.
Abdomen: She has no organomegaly, diffuse, or rebound.
Genital/Rectal: Deferred.
Musculoskeletal: She has symmetric muscle development, but reported stumbling with no falls.
Neurological: CN I-IV grossly in place as well as DTR complete.
Skin: No hemorrhage or raised erythematous plaques.
Diagnostic Results
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.
ASSESSMENT:
Lab Tests and Results: SAO2 – 97%.
MMSE: 18/30
Hemoglobin: A1C7.2%
Differential Diagnosis (DDX):
Dementia: It is a syndrome that occurs due to deterioration in memory, thinking, and behavior. It interferes with normal participation in daily activities (Weng et al., 2019). It is not a default part of aging, but it mostly affected the elderly. Some of the symptoms of the condition include mental and cognitive problems and confusion. It causes the inability to recognize normal things, speak, and remember places or time. It can be caused by a progressive loss of nerve cells or brain function loss due to minor strokes (Weng et al., 2019). Elderly people with dementia can suffer a lack of decision-making capabilities, memory, or language. It can lead to depression, anxiety or irritability.
Hearing and vision deficits: The disorder is common among elderly people due to sensory impairment. The condition can occur alongside dementia. Impairment of the sensory is common among elderly patients (Dening, 2019). It can also affect the balance of a patient leading to patient falls.
Hypothyroidism: The condition occurs when the thyroid gland does not secrete sufficient hormones. One of the major causes if an autoimmune disorder called Hashimoto’s thyroiditis (Horvath et al., 2017). Some of the condition symptoms include agitation, irritability, sluggishness, slow heart rate, fatigue, and feeling cold.
Diagnosis:
The most likely condition is dementia.
Treatment Plan:
The patient should take Cholinesterase inhibitors such as donepezil (Aricept). The drug is essential since it boosts the brain’s messenger level (Oh et al., 2017). The messenger is responsible for memory and judgment. If Alzheimer’s disease causes the condition, there is no known cure. However, the medication will temporarily improve the conditions. The patient should start by taking Aricept 5mg once a day (Oh et al., 2017). She will be observed for any improvement after a week. The physician will determine whether to increase the drug to 10mg depending on the improvements or side effects.
Health Promotion:
The patient should eat a healthy diet, drink plenty of water and sleep for long hours. She should also take some regular physical exercise. The patient should control other conditions such as diabetes and hypertension. She should avoid smoking or alcohol consumption (Oh et al., 2017). The patient needs to avoid stress or exposure to activities that can strain the body or mind. She should enjoy a rich social network to keep her mind alert and active.
Disease Prevention:
The patient should avoid exposure to factors that can increase the risk of developing dementia or experiencing a further deterioration of the nerve cells (Weng et al., 2019). For instance, she should avoid smoking and alcohol. Stress can also trigger the ability of the mind to function normally. It is important to continue taking the medication for dementia and other conditions. If they experience any abnormality, the patient should seek immediate help.
REFLECTION:
The clinical experience of carrying out a comprehensive examination is a learning opportunity. It provides a practical approach to multiple conditions that patients suffer from. The experience provides an opportunity to examine the relationship between various conditions. A background check of the family and examination of the symptoms and diagnosis are essential steps to diagnosis. Examining the various functionality of various parts of the body is essential during the differential diagnosis. It helps rule out the less likely conditions. It was also essential while narrowing down to a specific disease.
In the future, it will be interested in studying more complications affecting elderly patients. For example, I would like to study dementia and how to identify the condition from the symptoms. I want to study medication or health promotion strategies to help patients. I would also like to learn various lifestyle changes affecting the quality of health among elderly patients. I would like to know the warning signs of dementia and the lifestyle behavior that could trigger the condition.
I uphold the findings and analysis of differential diagnosis due to various symptoms she is suffering from. One of the major indicators is the mental exam that shows she has 18 out of 30 scores. Research shows that the patient should make lifestyle changes to enhance the quality of health. For instance, she should increase the social network, avoid smoking or drinking. She also needs to eat a healthy diet and exercise regularly. One of the major precautions is that the patient should continue taking current medication to keep all the other check conditions. She needs to start taking the new medication to enhance the messenger in the brain. Elderly patients should begin by taking 5mg of Aricept to avoid negative effects that can undermine life quality. She needs to come back for further assessment after a week. The healthcare practitioner will decide depending on the outcomes after a week.
References
Dening, K. H. (2019). Differentiating between dementia, delirium and depression in older people. Nursing Standard (Royal College of Nursing (Great Britain): 1987), 35(1), 43-50.
Horvath, K. J., Burns, T., Fernandez, C., Huh, J. T., Moorer, J., Thielke, S., … & Cooley, S. (2017). Reevaluation of a clinical resource for assessment of delirium, dementia, and depression. Gerontology & Geriatrics Education, 38(3), 245-256.
Oh, E. S., Fong, T. G., Hshieh, T. T., & Inouye, S. K. (2017). Delirium in older persons: advances in diagnosis and treatment. Jama, 318(12), 1161-1174.
Weng, C. F., Lin, K. P., Lu, F. P., Chen, J. H., Wen, C. J., Peng, J. H., … & Chan, D. C. (2019). Effects of depression, dementia and delirium on activities of daily living in elderly patients after discharge. BMC Geriatrics, 19(1), 261.
