Description
With the below case study, develop a case study presentation that includes the history of the present illness (HPI), appropriate positive and negative physical exam findings, past medical and surgical history, diagnostic results, diagnosis including differentials that were ruled out, and treatment plan.Your presentation should also include objectives for your audience (see the resource on Bloom’s Taxonomy), at least three possible discussion questions/prompts for your classmates to respond to, and at least five scholarly resources to support your diagnostic reasoning and treatment plan.State 3-4 objectives for the presentation that are targeted, clear, use appropriate verbs from Bloom’s taxonomy, and address what the audience will know or be able to do after viewing.
Unformatted Attachment Preview
1
Focused SOAP Note
Name
Institution
Course
Instructor
Date
1
2
Focused SOAP Note
Patient Information:
Initials: S.T.
Age: 80 Years
Sex: Female
Race: Caucasian
S (subjective)
CC (chief complaint): “I feel confused and pain on my back.”
HPI (history of present illness): An 80-year-old Caucasian female patient by the name of S.T.
was brought to the clinic by her caregiver, complaining of confusion and back pain. The patient’s
caregiver reports that the patient has been experiencing the condition for the past week, although
it has worsened today. The caregiver also adds that the condition has affected the patient’s entire
body, including the mind, back, and behaviors. The condition has been persistent for a duration
of one week and is characterized by other symptoms such as hallucinations, screaming, falls, and
decreased output. No aggravating or relieving factors have been reported to be associated with
the patient’s signs and symptoms. In addition, the symptoms the patient experiences have no
specific timing since they have been persistent throughout. She considers the symptoms to be so
severe that they interfere with the patient’s activities of daily living (ADLs).
Current Medications:
o Bupropion 150mg
o Divalproex sodium 125mg
o Quetiapine 100mg
o Synthroid 75mcg
o Gabapentin 300mg
2
3
Allergies: She reports no history of allergies
PMH:
o Seizure disorder
o Hypertension
o COPD
o Depression
o Anxiety
Soc and Substance Hx: S.T. is a retired nurse. She has never smoked or taken alcohol. She lives
with her caregiver. She has no specific hobby since she remains indoors most of her time. She
sometimes uses a walking stick as a health promotion strategy to prevent her from falling.
Fam Hx:
o Her father died at the age of 80 years from suicide associated with his schizophrenia
symptoms
o Her mother died of a heart attack at the age of 82 years
o Her elder brother died of a stroke
Surgical Hx: The patient underwent appendectomy at the age of 50 years
Mental Hx: The patient reports a history of depression and anxiety
Violence Hx: She reports no instances of experiencing violence
Reproductive Hx: She has four adult children who live in different states
ROS (review of symptoms):
•
GENERAL: The patient denies fatigue, fever, chills, and weight loss
•
HEENT: She denies headaches, visual issues, hearing loss, nosebleeds, and voice
hoarseness
•
SKIN: She denies itchiness and rashes on all parts of her body
3
4
•
CARDIOVASCULAR/CV: She denies edema, chest pain, and palpitations.
•
RESPIRATORY: She denies sputum production, coughing, and shortness of breath
•
GASTROINTESTINAL: She denies diarrhea, vomiting, nausea, and abdominal pain
•
GENITOURINARY: She admits to a burning sensation when urinating
•
NEUROLOGICAL: She denies numbness, loss of consciousness, tingling, and
headaches.
•
MUSCULOSKELETAL: She admits to back pain but no joint stiffness or pain
•
HEMATOLOGIC: She denies blood-related disorders
•
LYMPHATICS: She denies swollen nodes on the neck
•
PSYCHIATRIC: She reports depression and anxiety history
•
ENDOCRINOLOGIC: She admits to heat flushes for the past three decades
•
REPRODUCTIVE: She has four children
•
ALLERGIES: She denies hives, rhinitis, and eczema.
O (objective)
Physical exam:
•
Vital Signs/VS: Blood pressure: 98/69mmHg, Pulse: 52bpm, Respiratory rate: 18bpm,
Temperature: 99.2°F, SpO2: 94%
•
GENERAL: The patient is alert and oriented to name and self
•
HEENT: No scleral icterus noted. Pupils are equal, round, and sensitive to light
•
SKIN: Minor bruises noted on the skin on various parts of the body
•
CARDIOVASCULAR/CV: Heart rate and rhythm are regular
•
RESPIRATORY: Lung sounds are bilaterally clear.
•
GASTROINTESTINAL: Abdomen is non-distended and soft
4
5
•
NEUROLOGICAL: Cranial nerves are grossly intact
•
MUSCULOSKELETAL: The patient displays decreased mobility caused by back pain
Diagnostic Results: Pending results for urinalysis
A (assessment)
Differential diagnoses:
1. Primary dx: Delirium: Delirium involves a mental condition associated with confusion
and minimal awareness of the environmental surroundings. It develops suddenly, within
hours or a few days. Some signs and symptoms of this condition include agitation,
confusion, hallucination, and altered mental status (Wilson et al., 2020). It mostly occurs
among older adults. S.T. is likely to be experiencing delirium as a primary diagnosis
because she is an older adult and displays the mentioned delirium symptoms.
2. Ddx 1: Dehydration: Dehydration is a health issue associated with increased loss of body
fluids, especially due to increased urination and decreased fluid intake. This condition
can contribute to various health issues, such as falls, confusion, AMS, and decreased
urine output (Walavalkar et al., 2020). However, although S.T. experiences these
symptoms, dehydration is an inappropriate diagnosis because the patient does not have
dry skin or mucus membrane and has no history of orthostatic hypotension.
3. Ddx 2: Recurrent UTI: Recurrent UTI is an infection that frequently occurs within the
urinary tract, causing various symptoms such as a burning sensation when urinating,
increased urinary frequency, and urinary urgency (Peck & Shepherd, 2021). However,
although the patient experiences a burning sensation during urination, further diagnostics
should be considered to confirm or rule out this condition.
5
6
P (plan)
Diagnostic Studies
o Order urinalysis to determine whether the patient has recurrent UTI
o Perform a brain CT scan to determine the cause of altered mental status
o Perform a complete blood count (CBC) to determine whether the patient has a blood
infection (Stollings et al., 2021)
Treatment
o Administer intravenous fluid to enhance hydration
o Review the patient’s medications likely to be affecting the patient and discontinue them
Education:
o Inform the caregiver to monitor the patient always
o Educate the caregiver and the patient on the need for improved fluid intake to minimize
dehydration (Goldberg et al., 2020)
o Follow-Up: Schedule a follow-up appointment every two weeks for further assessments
Reflection:
Based on the assessment and diagnosis identified, I have learned several aspects. For
instance, older adults are prone to comorbidities due to their advanced age. Besides, dehydration
and infections can contribute to various health issues such as delirium and increased risk of falls.
Discussion Questions
1. What is the likely cause of the patient’s hallucinations?
2. What is the relationship between delirium and recurrent UTI?
3. Are the symptoms that the patient experiences likely to be the side effects of her
medications?
6
7
References
Goldberg, T. E., Chen, C., Wang, Y., Jung, E., Swanson, A., Ing, C., … & Moitra, V. (2020).
Association of delirium with long-term cognitive decline: a meta-analysis. JAMA
neurology, 77(11), 1373-1381. 10.1001/jamaneurol.2020.2273
Peck, J., & Shepherd, J. P. (2021). Recurrent urinary tract infections: diagnosis, treatment, and
prevention. Obstetrics and Gynecology Clinics, 48(3), 501–513.
https://doi.org/10.1016/j.ogc.2021.05.005
Stollings, J. L., Kotfis, K., Chanques, G., Pun, B. T., Pandharipande, P. P., & Ely, E. W. (2021).
Delirium in critical illness: Clinical manifestations, outcomes, and management. Intensive
care medicine, 47(10), 1089–1103. https://doi.org/10.1007/s00134-021-06503-1
Walavalkar, S. M., Rayas, R. V., Shyam, A., & Sancheti, P. K. Knowledge of dehydration and
hydration practices among elderly individuals. Journal of Society of Indian
Physiotherapists, 10–4103. 10.4103/jsip.jsip_60_23
Wilson, J. E., Mart, M. F., Cunningham, C., Shehabi, Y., Girard, T. D., MacLullich, A. M., … &
Ely, E. W. (2020). Delirium. Nature Reviews Disease Primers, 6(1), 90.
https://doi.org/10.1038/s41572-020-00223-4
7
Purchase answer to see full
attachment
