SOAP NOTE: Week 2: Assessing, Diagnosing, and Treating Dementia, Delirium, and Depression

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. 

Also Read: Focused SOAP Note Writing Service

 

Week 2 Case 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 (https://www.heartandstroke.ca/-/media/pdf-files/canada/clinical-update/allen-huang-cognitive-screening-toolkit.ashx?la=en&hash=631B35521724C28268D0C2130D07A401E33CDBB0. Click or tap if you trust this link." data-saferedirecturl="https://www.google.com/url?q=https://nam04.safelinks.protection.outlook.com/?url%3Dhttps%253A%252F%252Fwww.heartandstroke.ca%252F-%252Fmedia%252Fpdf-files%252Fcanada%252Fclinical-update%252Fallen-huang-cognitive-screening-toolkit.ashx%253Fla%253Den%2526hash%253D631B35521724C28268D0C2130D07A401E33CDBB0%26data%3D04%257C01%257Cbeverly.spencer%2540waldenu.edu%257Ca052885187de43f15bae08d8970fbdac%257C7e53ec4ad32542289e0ea55a6b8892d5%257C0%257C0%257C637425441170920250%257CUnknown%257CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%253D%257C1000%26sdata%3D9NBXQ7KfUbNrtCegsRImPAHHmARcEucV7EJJQNNY7ic%253D%26reserved%3D0&source=gmail&ust=1695303554562000&usg=AOvVaw3_24sMi2QwLfr1_KEuCPA_">Mental State Assessment Tests). Make sure you document the patient’s score in your SOAP note document. Also review the Geriatric Depression Assessment (https://ezp.waldenulibrary.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=105275304&site=eds-live&scope=site. Click or tap if you trust this link." data-saferedirecturl="https://www.google.com/url?q=https://nam04.safelinks.protection.outlook.com/?url%3Dhttps%253A%252F%252Fezp.waldenulibrary.org%252Flogin%253Furl%253Dhttps%253A%252F%252Fsearch.ebscohost.com%252Flogin.aspx%253Fdirect%253Dtrue%2526db%253Drzh%2526AN%253D105275304%2526site%253Deds-live%2526scope%253Dsite%26data%3D04%257C01%257Cbeverly.spencer%2540waldenu.edu%257Ca052885187de43f15bae08d8970fbdac%257C7e53ec4ad32542289e0ea55a6b8892d5%257C0%257C0%257C637425441170930248%257CUnknown%257CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%253D%257C1000%26sdata%3DI%252B05wNo4udUHuzla9yf%252Fmvx8eSaK0MJYu2tSqHDhBMA%253D%26reserved%3D0&source=gmail&ust=1695303554562000&usg=AOvVaw2MwIzzsBGuRrD0cxFee77f">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

Week 2:  Psychosocial Disorders Sample SOAP Note

Patient Information: 

Initials: Ms. P Age: 70 Sex: Female Race: Undisclosed

SUBJECTIVE

CC (chief complaint):  Patient experiences confusion and easily agitated.

HPI (history of present illness):  Ms. Peters is a 70-year-old female that was brought to the clinic by her son experiencing acute confusion that included being agitated and restlessness.  The patient also has a known history of being diagnosed with dementia which she has been managing with Aricept 10 mg daily.  According to her son Jared, 2 days ago Mrs. P began to be more confused than normal and she was also very easily agitated.  The son also reported that the previous day, she was not able to remember where she was in her own home. 3 days ago she had a doctor's appointment and due to high blood pressure, her HCTZ (hydrochlorothiazide) was increased to 50 mg. According to the last Mini-Mental state Exam, she scored 18/30. The score was repeated but did not change.  There were no reports of falls or recent contributing traumas. Ms. Peters and her son also denies any changes in routine regimens or diet. There is no reported dysuria, no nausea, no fever, 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, and Alendronate 70mg orally once a week. 

Allergies: Atorvastatin.

PMHx: Hypertension, Diabetes, Osteoporosis, Chronic Allergic Rhinitis

Soc and Substance Hx: Ms. P lives with her son, does not have a history of tobacco or alcohol use. She is a widow and unemployed. 

Fam Hx: Family has a history of Diabetes, Hypertension, Osteoporosis, and Allergic Rhinitis

Surgical Hx:  None Reported

Mental Hx: Dementia, no history of self-harm practices 

Violence Hx:  None

Reproductive Hx:  Not applicable

ROS (review of symptoms): 

• General:  Patient appears well-nourished, confused, denies change in weight
• Head: No reports of headaches
• EENT (eyes, ears, nose, and throat): Normal

HEENT: 

• Eyes: Fair
• Ears, Nose, Throat: Normal

SKIN:  None

CARDIOVASCULAR: Normal

RESPIRATORY: Normal

GASTROINTESTINAL: Normal

GENITOURINARY: Normal

NEUROLOGICAL: Confusion

MUSCULOSKELETAL: Normal

HEMATOLOGIC: Normal

LYMPHATICS: Normal

PSYCHIATRIC: History of Dementia, reports confusion

ENDOCRINOLOGIC: Normal

REPRODUCTIVE: None Applicable

ALLERGIES: History of rhinitis.

VITAL SIGNS: BP 98.1 120/64 HR-72 20

OBJECTIVE

Physical exam:  The patient is alert by easily distracted as was observed during the clinical interview.  She has fair eye contact. Her speech is also clear and she is coherent though appears tangible at times.  She also makes no unusual motor movements were also she does not demonstrate unusual motor movements like tics. The patient also denies visual or auditory hallucinations. She has never had suicidal thoughts or ideations. The patient is alert though disoriented to place and time. The patient denies any falls or feeling any pain. Interview with the son reports that she has had some 'stumbling' and balance issue though no reported case of falls. 

Diagnostic results: I

1. CT Scan Head – Diffuse Cerebral Atrophy
2. CXR – no cardiopulmonary findings. WNL
3. MMSE – According to repeated results, the patient scored 18 out of 30 with primary deficits in orientation, registration, attention, and calculation, including recall at the previous visit. The results remained the same in repeated tests suggesting moderate dementia. 
4. Hemoglobin – A1C 7.2%

ASSESSMENT

Differential diagnoses: 

1. Dementia – This is a condition that is comprised of a group of symptom that affects the individual memory, thinking, and their social abilities to the extent that it will interfere with their daily life.  The disease is not always specific but could be triggered by several different diseases.  Even though dementia is known to affect memory loss, this could be as a result of other causes; when someone has memory loss alone it may not mean that it is dementia so tests have to be done.  In the case of Ms. P MMS test was done which she repeatedly scored 18/30.  Other aspects of dementia will include cognitive changes which were witnessed in Ms. P such as; difficulty communicating or finding words, memory loss as noticed by her son, difficult reasoning,  handling complex tasks, challenges with visual and spatial abilities, difficulty in self-organization confusion, and disorientation.  Other psychological changes will include; Anxiety, depression, personality changes, paranoia, inappropriate behavior, and hallucinations. 
2. Depression – This is usually referred to as a mood disorder that causes a persistent feeling of sadness or loss of interest.  When someone is in this condition it will affect how they think, feel, and behave or will lead to several emotional and physical problems. The individual may have trouble having to deal with normal daily activities or they may not be interested in living, (being suicidal) (Mayo Clinic, 2018).  Depression is often full of many episodes for which they can experience different symptoms including a feeling of tearfulness, sadness, angry outbursts, insomnia,  body movement, trouble thinking,  anxiety, and unexplained physical problems for which was not reported in Ms. P
3. Delirium – This is an abrupt change in the brain which causes mental emotional and mental confusion. When some are delirious they find it difficult to think, remember, pay attention, sleep among other factors. Delirium is also known to lead to other conditions such as pneumonia, which interferes with normal brain function (Badii, 2019). Other symptoms are caused by medications that can disrupt individual brain chemicals. Delirium is also common for people who take alcohol during withdrawal or someone who is trying to quit smoking. 

PLAN

Medication

1. Donepezil, –5 mg PO qHS initially, may increase to 10 mg/day after 4-6 weeks if warranted (Mescape, 2020).  Helps to boost levels of chemical messenger for memory and judgment.
2.  Memantine - (CrCl 5-29 mL/min): Not to exceed 14 mg/day (extended-release) or 5 mg BID (prompt-release) (Medscape, 2019). 
3. Other medications. 

Therapeutic interventions

Ms. P and his son should work with an occupational therapist who will be able to show how they can make their home safer and teach her ways to cope with her diagnosed condition.  This is important since people with dementia are often prone to accidents as to condition progresses.  Also, make environmental modification by reducing noise and clutter to make it easier for Ms. P to focus and function properly.  Some objects should be kept away like car keys and knives to avoid personal risks or harm.

Panned follow up visits. 

The patient is booked for follow up within 4 weeks to check on the progress of the condition and response to medication. 

Reflection

Based on the patient assessment it is evident that Ms. P suffers from dementia. This conclusion was arrived at based on the diagnostic results and the type of symptoms that she manifested. A person with dementia will experience memory loss which in this case was noticed by her son (Mayo Clinic, 2019). Ms. P had difficulty communicating or finding words, she could not reason freely, reported having partial difficulty with her vision, depicted confusion, and poor coordination.  The diagnostic MMSE test reported that she repeatedly scored 18/30 showing the possibility of dementia.  In conducting the assessment I kept thinking of the future for people living with dementia since currently there is no cure. However, with various interventions, a person living with the condition can live a long and satisfactory life that would be expected. Patients with the condition such as that of Ms. P must be well educated to understand their condition. Also support groups and family is usually very helpful in ensuring therapeutic interventions are adhered to.  Most people and their families will deny the need for a support group, however, learning various coping skills can help the patient and her family manage though the condition. 

Dementia is often described as the development of an individual in reverse. This is because what is believed is to be learned and stored in the human brain over many years. However, dementia acts as if it deletes each memory slowly by slowly until the individual brain cannot remember even the most recent things. As the disease progresses the person one used to know becomes a burden that families have to learn to live with.  They will become physically, emotionally, and mentally dependent throughout their lives.  However, one should understand that as much as dementia is a condition of the mind, it will manifest itself through difficulty in communication, memory loss failing to recall how to care for individual self, and not being able to recognize family members or friends close to them. 

References

Badii, C. (2019, August 2). What's delirium and how does it happen? Healthline. https://www.healthline.com/health/delirium

Mayo Clinic. (2018, February 3). Depression (major depressive disorder) - Symptoms and causes. https://www.mayoclinic.org/diseases-conditions/depression/symptoms-causes/syc-20356007

Mayo Clinic. (2019, April 19). Dementia - Symptoms and causes. https://www.mayoclinic.org/diseases-conditions/dementia/symptoms-causes/syc-20352013

Medscape. (2019, September 28). Namenda XR (memantine) dosing, indications, interactions, adverse effects, and more. Medscape Drugs & Diseases - Comprehensive peer-reviewed medical condition, surgery, and clinical procedure articles with symptoms, diagnosis, staging, treatment, drugs and medications, prognosis, follow-up, and pictures. https://reference.medscape.com/drug/namenda-xr-memantine-343063

Mescape. (2020, January 27). Aricept (donepezil) dosing, indications, interactions, adverse effects, and more. https://reference.medscape.com/drug/aricept-donepezil-343057

 

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