Focused SOAP Note Based on Ms. Washington’s Case (Case Study Sample)

Instructions:

Week 2 Case 2: Alzheimer’s Ms. Washington is a 67-year-old African American female who is brought to your office by her daughter with concerns of “forgetfulness.” She has lived with her daughter for 4 years now, and her daughter reports noticing she asks the same questions even after they have been answered. She even reports her mom getting lost in Walmart recently. Ms. Washington has lived with her daughter since losing her husband of 57 years, about 4 years ago. Her daughter states her mother is a retired teacher and usually very astute but notices more forgetfulness. According to Ms. Washington’s daughter, Angela, her mom has been demonstrating increased forgetfulness of more recent things but can easily recall historical moments and events. She also reports that sometimes her mom has difficulty “finding the right words” in a conversation, and then will shift to an entirely different line of conversation. She also said her mother will “laugh off” things when she forgets important appointments and/or become upset or critical of others who try to point these things out. Note: Be sure to review the Mini-Mental State Exam (MMSE) and how to interpret results. Use the MMSE, in the attached document, to determine the patient’s MMSE score in the video. Make sure you document the patient’s score in your SOAP note document: Mental State Assessment Tests. Ms. Washington is a 67-year-old female who is alert, cooperative with 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 and oriented to person, partially oriented to place but is disoriented to time and place. (She reported that she thought was headed to work but “wound up here,” referring to your office, at which point she begins to laugh it off.) She denies any falls or pain. All other Review of System and Physical Exam findings are negative other than stated. PMH: Hypertension, Hyperlipidemia, Osteoporosis Allergies: Penicillin, Lisinopril Medications: Amlodipine 10mg daily HCTZ 12.5mg daily Multivitamin daily Atorvastatin 40mg 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. Washington scores 18 out of 30 with primary deficits in orientation, registration, attention and calculation, and recall. The score suggests moderate dementia. 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. Provide a review of systems. Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results? Assessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. 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/or any planned follow-up visits. Finally, include a reflection statement on the case that describes insights or lessons learned, and A DISCUSSION OF HEALTH PROMOTION AND DISEASE PREVENTION FOR THE PATIENT, TAKING INTO CONSIDERATION PATIENT FACTORS, PAST MEDICAL HISTORY (PMH), AND OTHER RISK FACTORS. Provide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case. source..

Content:

Focused SOAP Note Based on Ms. Washington’s Case Name Institutional Affiliation Course Name and Code Instructor Date Focused SOAP Note Based on Ms. Washington’s Case Patient Information Name: Ms. Washington Age: 67 years Gender: Female Race: African American S. CC: Forgetfulness HPI: Ms. Washington is an African-American female aged 67. She has been accompanied by her daughter, Angela, due to concerns of forgetfulness. She has lived with Angela for 4 years since the passing of her husband. Angela indicates that her mom has made it a habit to ask the same questions repeatedly, even after receiving answers. Furthermore, Ms. Washington’s daughter indicates that her mom recently got lost in a Walmart store. While she can easily recall historical moments, Ms. Washington’s forgetfulness seems more pronounced for recent events. Angela notes that her mom occasionally struggles to find the right words in conversations, and when that happens, Ms. Washington would abruptly shift to entirely different topics. Her daughter also notes that her mom has developed the tendency to either become distressed when reminded of missed appointments or laugh off her forgetfulness. Current Medications: Current medications include the following. * Alendronate 70mg orally once a week * Atorvastatin 40mg daily * Multivitamin daily * HCTZ 12.5mg daily * Amlodipine 10mg daily Allergies: Lisinopril, Penicillin PMHx (Past Medical History): Osteoporosis, Hyperlipidemia, HypertensionSoc and Substance Hx: While no major hobbies are indicated in the case study, Ms. Washington is a retired teacher. With her husband having passed away four years ago, Ms. Washington is a widow. She lives with her daughter, Angela. Ms. Washington’s previous and/or current alcohol and/or tobacco use is not mentioned in the case study. Fam Hx: Neither contagious/chronic illnesses nor illnesses with genetic predisposition are mentioned in the case study. While it is clear that Ms. Washington’s husband passed away four years ago, no specific cause or reason for death is mentioned. Surgical Hx: No prior surgical procedures are mentioned in the case study. Mental Hx: According to the case study, Ms. Washington has been diagnosed and treated for moderate dementia based on her MMSE score. Current concerns include forgetfulness and difficulty finding the right words. While no history of self-harm practices is mentioned in the case study, Ms. Washington denied any homicidal or suicidal ideation. Violence Hx: Issues or concerns about safety are not mentioned in the case. Reproductive Hx: The date of LMP is not provided in the case. Ms. Washington is neither pregnant nor lactating. Information regarding sexual concerns, contraceptive use, and types of intercourse are not mentioned in the case study. ROS: All other findings are negative O. Physical Exam: * Ms. Washington is generally alert and cooperative. * She exhibits fair eye contact. * Despite being tangential at times, Ms. Washington’s speech is clear and coherent. * She displays no unusual motor movements or tics. * Ms. Washington denies any auditory or visual hallucinations. * She denies any suicidal ideations or thoughts. * While she is disoriented to place and time, Ms. Washington is partly oriented to place. * Ms. Washington denies pain or falls. Diagnostic Results: * Head CT scan – diffused Cerebral Atrophy * Chest x-ray – within normal limits. No cardiopulmonary findings * MMSE test – score of 18/30, suggesting moderate dementia. She has primary deficits in recall, attention and calculation, registration, and orientation. A. Differential Diagnoses: * Alzheimer’s disease: Given Ms. Washington’s forgetfulness, difficulty finding the right words, and recent onset of disorientation, Alzheimer’s disease is a significant consideration. * Vascular Dementia: Hypertension and hyperlipidemia occurrence raise the possibility of vascular dementia, especially with the noted cerebral atrophy. * Age-Related Cognitive Decline: Normal age-related cognitive changes may contribute to Ms. Washington's symptoms. P. Plan: * Refer Ms. Washington to a neurologist for further evaluation and confirmation of the diagnosis. * Recommend additional cognitive testing, including neuropsychological assessments. * Initiate discussions with Ms. Washington and her daughter about long-term care planning and support services. * Encourage Ms. Washington to continue taking her current medications for hypertension, hyperlipidemia, and osteoporosis as prescribed. * Provide education to Ms. Washington’s daughter and family about dementia, its progression, and the importance of a supportive and safe environment. Reflection: I agree with my preceptor’s treatment of Ms. Washington. Based on the patient’s age, instances of forgetfulness, and cognitive decline, it was most appropriate to test for dementia (Mayo Clinic, 2023; NIH, 2020). According to Gallegos et al. (2022), the Mini-Mental State Exam (MMSE) is appropriate for testing for dementia. Therefore, the initial assessments, including the MMSE and the CT head scan revealing diffuse cerebral atrophy accomplished by my preceptor, provide valuable diagnostic insights about moderate dementia and are consistent with Ms. Washington’s symptoms and test results. Despite being a valuable tool, the MMSE may not provide a complete picture of Ms. Washington’s cognitive function (Vyas et al., 2021). However, I would emphasize the importance of considering a more comprehensive assessment and diagnostic workup. Thus, I would recommend additional neuropsychological testing and a thorough review of Ms. Washington’s medical history (Arevalo-Rodriguez et al., 2015), including potential reversible causes of cognitive deterioration, for example metabolic issues or medication side effects. From the case, I have learned the importance of implementing a sensitive and patient-centered approach for early detection of cognitive decline and/or dementia. Ms. Washington...

Get the Whole Paper!

Not exactly what you need?

Do you need a custom essay? Order right now:

Order

Focused SOAP Note Based on Ms. Washington’s Case (Case Study Sample)

Other Topics: