NURS 6540

To prepare:

Review the case study provided by your Instructor. 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.
Access the Focused SOAP Note Template in this week’s Resources.
The 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.

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:

CXR—no cardiopulmonary findings. WNL
CT head—diffuse Cerebral Atrophy
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.
Hemoglobin A1C7.2%

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

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Solution

Focused SOAP Note: Case Study 1

Patient Information:

Initials: M.P

Age: 70

Gender: Female

SUBJECTIVE

CC: “Acute confusion and some agitation and restlessness.”

History of the Presented Illnesses (HPI)

The client, Ms. Peters, is a female aged 70 years. She is accompanied by her son, Jared, to the office. He reports various clinical manifestations, including acute confusion, restlessness, and agitation. Jared reported that the client started being confused more than usual and becoming easily agitated 2 days ago. He added that the client couldn’t remember where she was the previous day. In the previous three days, the client had a doctor’s appointment during which her hydrochlorothiazide dosage was titrated upwards to 50 mg following increased bp. Her son added that she has a history of dementia, which she has been managing with Aricept 10 mg taken daily. However, Jared denies any recent contributing traumas or falls. The client also denies routine regimens or diet changes. The client and her son deny fever, nausea, or vomiting.

Current 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

PMH

  • Hypertension,
  • Diabetes,
  • Osteoporosis,
  • Chronic Allergic Rhinitis

ROS

ENDOCRINE: The patient denies goiter, fever, or general weakness.

CARDIOVASCULAR: Denies rapid heart rates.

MUSCULAR: Denies muscle pains.

NERVOUS: Denies headache.

DIGESTIVE: Denies nausea or vomiting.

SKIN: Denies rashes or color changes.

URINARY: Denies persistent urge to urinate or burning sensation while urinating.

Mental: Reports acute confusion, agitation, and restlessness.

OBJECTIVE:

Vitals: 98.1 120/64 HR-72 20

Physical Examination

General

Ms. Peters is a female aged 70 years. The client was not alert, easily distracted, and disoriented during the interview to time and place. She tries to maintain eye contact during the interview. She has a coherent and clear and speech, although sometimes it becomes tangential. She does not make any motor movements nor demonstrates tics. The client denies any auditory or visual hallucinations. She also denies suicidal ideations or thoughts. She denies any pain or falls despite having “stumbling” and balance issues.

NEUROLOGIC: Not alert, Loss of senses

CARDIOVASCULAR: Regular heart rates and rhythms

INTEGUMENTARY: No skin lesions or rashes are seen.

Diagnostics

Mini-Mental State Exam (MMSE) Score: 18/30 in repeated assessment. The MMSE score between 13 and 18 characterizes moderate dementia (the Cochrane Collaboration, 2021). The client reported primary deficits in registration, orientation, alertness, attention, and calculation in the previous visit. Similar results were obtained during today’s interview.

ASSESSMENT

            Differential diagnosis should be conducted for appropriate diagnosis and treatment. The client’s possible diagnosis from the highest to most minor priority areas is listed below.

  1. Moderate Dementia- Primary diagnosis
  2. Alzheimer’s disease
  • Parkinson’s disease

The client’s primary diagnosis is moderate dementia. This condition was selected as the primary diagnosis based on presented history, physical examination, and the Mini-Mental State Exam (MMSE) score. Dementia is characterized by various clinical manifestations, including confusion and disorientation, memory loss, difficulty with motor functions and coordination, anxiety, paranoia, inappropriate behavior, agitation, hallucinations. Pertinent positives in this client, including confusion and disorientation, difficulty with motor functions and coordination, and agitation, indicate that she has dementia. However, this scenario is associated with some negatives, including memory loss, anxiety, paranoia, inappropriate behavior, or hallucinations. In addition to clinical manifestation, dementia qualifies as the primary diagnosis based on the Mini-Mental State Exam (MMSE) score. This client scored 18/30 in repeated assessments. This score indicates that the client has moderate dementia, characterized by an MMSE score between 13 and 20 (the Cochrane Collaboration, 2021).

The second differential diagnosis for this client is Alzheimer’s disease. This condition is characterized by various clinical manifestations, including depression, social withdrawal, mood swings, apathy, distrust in others, irritability and aggressiveness, wandering, and changes in sleeping habits. Dementia is a possible diagnosis for this client since irritability and aggressiveness are among the chief complaints reported by her son during the visit. However, this condition is ruled out due to the absence of significant symptoms of Alzheimer’s disease, including depression, social withdrawal, mood swings, apathy, distrust in others, wandering, and changes in sleeping habits.

The final diagnosis for this client is Parkinson’s disease, which is characterized by trembling in hands, legs, arms, jaw, or head; limbs and trunk stiffness; slowness of movement; and impaired coordination and balance that sometimes results in falls. Thus, this client might have Parkinson’s disease since her son reports “stumbling” and balance issues, although they do not lead to falling. Nonetheless, this condition is ruled out due to the absence of the most common symptoms of Parkinson’s disease, such as trembling in hands, legs, arms, jaw, or head and limbs and trunk stiffness.

PLAN

Based on the provided subjective data and the Mini-Mental State Exam (MMSE) score, moderate dementia is selected as the appropriate diagnosis for this client. Hence, an appropriate treatment plan for dementia should be developed for this client to manage the presented symptoms. Unfortunately, dementia does not have a cure. Hence, treatment goals include maintaining the client’s quality of life, improving functioning capability, enhancing recognition capacity, fostering a safe environment, and promoting social engagement.

Dementia is a mental illness mainly characterized by cognitive and memory impairment and memory loss. This clinical manifestation of dementia is evident in this client. Her son reports that the client could not recognize her location when she was in her home some days ago. Thus, non-pharmacological intervention should be recommended as the first-line treatment for this client to manage symptoms associated with memory deficit such as agitation or aggression, improving the client’s cognitive and memory functioning. According to Berg-Weger and Stewart (2017), physical activities and intellectual engagement are non-pharmacological interventions that improve one’s cognitive functioning. Other non-pharmacological treatment options for dementia suitable for this client are psycho-educational interventions and behavioral management therapy (Lee et al., 2019). Psycho-educational interventions will help the client to maintain their health and wellbeing. Behavioral management therapy will manage the client’s challenging behavioral patterns, including agitation, confusion, and aggressiveness. Additionally, the client should be recommended pharmacological intervention, including Donepezil. According to Ijaopo (2017), this medication effectively manages mild-to-moderate symptoms of dementia. Therefore, Donepezil 5 mg daily will be administered for 4 to 6 weeks to manage agitation, confusion, and restlessness in this client. Based on the client’s response, this dosage can be titrated upwards to 10mg daily after the first 6 weeks.

The client should be referred to other healthcare providers, particularly primary care providers, to manage other conditions, including hypertension, diabetes, osteoporosis, and chronic allergic rhinitis, thus providing the client with holistic care. Patient education is also essential to enhance the management of these conditions, especially diabetes and hypertension. Caregiver support is also required due to cognitive and memory impairment associated with dementia. The client will be scheduled for follow-up visits every 4 weeks to allow the healthcare providers to monitor her response and adjust the treatment plan based on the assessment results and reported drug side effects and reactions.

Health promotion and disease prevention are essential in this client to provide her with holistic care, thereby improving her quality of life and overall well-being. The client should be advised to make lifestyle modifications, including reducing salt intake, consuming a balanced diet with low calories, and increasing physical activities. These lifestyle changes will enhance the management of existing conditions, particularly hypertension and diabetes, preventing further complications associated with these conditions.

I have learned that dementia is mainly characterized by cognitive and memory deficits. Therefore, pharmacological and non-pharmacological treatments are prescribed to individuals with this condition to improve their memory and cognitive functioning.

 

References

Berg-Weger, M., & Stewart, D. B. (2017). Non-pharmacologic interventions for persons with dementia. Missouri medicine114(2), 116.

Ijaopo, E. O. (2017). Dementia-related agitation: a review of non-pharmacological interventions and analysis of risks and benefits of pharmacotherapy. Translational psychiatry7(10), e1250-e1250.

Lee, G. E., Kim, J. Y., Jung, J. H., won Kang, H., & Jung, I. C. (2019). Non-pharmacological interventions for patients with dementia: A protocol for a systematic review and meta-analysis. Medicine98(38).

The Cochrane Collaboration. (2021). Mini-Mental State Examination (MMSE) for the detection of dementia in people aged over 65. Cochrane. Org. https://www.cochrane.org/CD011145/DEMENTIA_mini-mental-state-examination-mmse-detection-dementia-people-aged-over-65