SOAP note

CASE STUDY-SOAP NOTE

 

Week #: 4

Case Study-SOAP note

 

Patient Name: XXX

MRN: XXX

 

Date of Service: 11/31/2023

 

Start Time: 11:00 End Time: 11:45

 

Billing Code(s): 90213, 90836

 

 

Accompanied by: Alone

 

CC: “Someone is trying to kill me.”

 

 

HPI: Patient is a 68-year-old male, recently admitted to the Alzheimer Unit of a long-term care facility. He presents with confusion, verbal aggression towards staff, depressive symptoms, throwing food, and instances of wandering and attempting to leave. Recently, he was evaluated in the ED after exhibiting physical aggression towards family members,confuse, threats to burn down his house, and paranoia. The medical evaluation in the ED was unremarkable.

 

S- He was discharged from the ED and since arriving at the facility, he has been verbally aggressive with staff, depressed, throwing food, wanders around, and tries to leave. He does not answer most questions when asked by staff and appears agitated.

Crisis Issues: Reported thoughts of harming others. Positive for visual hallucinations and paranoia.

 

Medical History: Diagnosed with Alzheimer’s Disease 2 years ago (diagnosed based on symptoms and amyloid PET scan), hyperlipidemia (HLD), presbycusis, osteoarthritis (OA)

Social History: Former smoker 1/2 pack per day x 20 years, no substance abuse. ETOH 2-3 drinks on the weekends x 10 years. Married. Previously employed as accountant

Family History: No history of dementia or mental health disorders. Mother deceased from colon cancer. Father deceased from MI. Son is 31 and healthy.

Medications: Donepezil 5 mg PO HS, Prazosin 1 mg PO HS, Crestor 20mg PO at HS

Allergies: NKDA

 

 

O-

Physical Exam:

Head: Normocephalic, atraumatic.

Cardiac: Regular rate and rhythm, no murmurs.

Lungs: Clear to auscultation anteriorly and posteriorly.

Abdomen: Bowel sounds active x 4, soft, non-tender, last bowel movement 2 days ago.

Musculoskeletal: Moves all extremities,ambulatory but exhibits abnormal and unsteady gait.

Neurological: Grossly intact cranial nerves, but full evaluation was not feasible due to uncooperativeness. Deep tendon reflexes 1+ and symmetric. Could not complete Mini-Mental State Examination (MMSE).

 

Vitals: Temp: 98.8°F, Pulse: 88, Resp: 18, BP: 132/78.

 

 

MSE:

General appearance and Manner: Appears agitated, uncooperative,

Speech: rapid and confused speech,

Mood: agitated

Affect: Congruent with mood

Thought Process: Non-logical and not goal directed,

Thought Content: evidence of delusions or paranoia.

Behavior: inattentive, and distracted, slight hyperactivity, observed pacing hallways.

Orientation: Disoriented to place and time; able to state his name

Memory: Not formally assessed

Judgement/Insight: poor/inadequate

 

 

A –

 

Differential Diagnoses:

 

1. Delirium (F05.9). Delirium frequently occurs in elderly individuals with dementia, but it is often overlooked (n.d.)

2. Urinary Tract Infection (N39.0): UTI can lead to delirium in elderly population

3. Major Depressive Disorder with Psychotic Features (F33.3). Major depression with psychotic features is a mental condition where an individual experiences depression coupled with a detachment from reality, known as psychosis. (MedlinePlus, 2022).

 

 

Definitive Diagnosis:

Alzheimer’s Disease: Behavioral and psychological symptoms associated with Alzheimer’s Disease include confusion, aggression, threats, paranoia, depressive symptoms. The rationale please

 

P-

 

Pharmacological Intervention:

· Continue Donepezil 5 mg PO HS for Alzheimer’s.

· Consider reviewing the efficacy of Prazosin 1 mg PO HS, given the current behavioral symptoms.

· Continue Crestor 20mg PO at HS for HLD.

· New Medications:

· Lorazepam 0.5mg PO PRN for acute agitation, with maximum dosage of 1mg/day.

· Haloperidol 0.5mg PO PRN for severe aggression, with maximum dosage of 2mg/day.

 

Non-Pharmacological Interventions:

· Instructions for staff:

· Administer PRN medications only when non-pharmacological interventions are ineffective.

· Do not combine PRN medications.

· Monitor patient closely after administration for side effects and therapeutic effects.

· Monitor vitals every 4 hours for 24 hours after administering PRN medications.

· Monitor for signs of EPS (extrapyramidal symptoms) when Haloperidol is given.

· Staff to document the time and reason PRN medications were administered and their effect.

· Implement a consistent daily routine to minimize disorientation.

· Monitor closely to prevent wandering and ensure safety.

· Consider a structured activity plan to address pacing/hyperactivity.

· Ensure the patient’s room is safe and familiar items from home are available.

· Consider a nightlight to reduce nighttime agitation.

· Engage with family for more insights into his baseline behavior and any triggers.

· Train staff on therapeutic communication techniques and de-escalation strategies.

 

Follow-Up:

· Schedule follow-up in 1 week to reassess behavior and medication efficacy.

Referrals: Case management

 

 

What medications would you prescribe? Why?

 

Lorazepam: It’s a benzodiazepine which can quickly alleviate acute agitation and anxiety. It’s often used in geriatric patients in low doses due to its shorter half-life compared to other benzodiazepines.

Haloperidol: An antipsychotic used for severe aggression or hallucinations.

 

What doses?

 

Lorazepam: 0.5mg PO PRN

Haloperidol: 0.5mg PO PRN

 

Would you have these listed as standing orders for the nursing home staff or would you want to be notified before given to verify and determine need?

 

PRN orders can be standing orders for the nursing home staff. However, if PRN medications are used frequently e.g., more than 2 consecutive days, the provider should be notified for re-evaluation.

 

Would you want to visually see the patient before having the medications given?

 

Yes, patient should be evaluated especially in initial stages. However, in practical long-term care settings, nursing staff would assess and administer, especially during acute episodes.

 

What monitoring would need to be provided after medication is given?

 

Vital signs, oxygen saturation, and potential side effects should be closely monitored. Especially for extrapyramidal symptoms (EPS) after Haloperidol administration.

 

What documentation would need to be provided and how often for the medication to be continued?

 

Every time a PRN medication is administered, the reason for its use and the patient’s response should be documented. Also, note any side effects observed. Review of PRN medications should be done weekly or more often if used frequently.

 

Would the medication be considered chemical restraints? Why or Why not?

 

Yes, medications like Haloperidol can be considered chemical restraints when used to control behavior and not for therapeutic intent. It’s essential that they are used ethically, as a last resort, and for the shortest duration possible. A chemical restraint medication is used as a final option when other less intrusive methods are ineffective (Davis, 2022). Their purpose should be the safety of the patient and others, and they should not be used for staff convenience.

 

 

References

 

Alzheimer’s & Dementia Resource Center. (n.d.). Dementia, Delirium, and Alzheimer’s Disease. Retrieved from https://adrccares.org/dementia-delirium-and-alzheimers-disease/

Davis, (2022). What is an Example of Chemical Restraint? Retrieved from https://www.medicinenet.com/what_is_an_example_of_chemical_ restraint/article.htm

MedlinePlus. (2022). Major Depression with Psychotic Features. Retrieved from https://medlineplus.gov/ency/article/000933.htm