Dementia, Delirium, and Depression
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 assessment 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.
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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 differential 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.
Solution
Focused SOAP Note Template
Patient Information:
Initials, Age- 67 years old, Sex- Female, Race- African-American Initials- Ms. W
S (subjective)
CC Ms. W has a problem with forgetfulness
HPI: The patient has in the recent past been experiencing forgetfulness.
- Location: Mind
- Onset: Recent past
- Character: N/A
- Associated signs and symptoms: Difficulty finding the right words, laughing off things, and getting upset easily
- Timing: Most of the time
- Exacerbating/relieving factors: N/A
- Severity: 8/10 pain scale
Current Medications: Amlodipine 10 mg, HCTZ 25 mg daily Multivitamin, Atorvastatin 40 mg daily, Alendronate 70 mg orally once a week.
Allergies: Penicillin, Lisinopril
PMHx: The patient suffers from hypertension, osteoporosis, hyperlipidemia
Soc and Substance Hx: She is a retired elementary teacher. She lives with her daughter since the death of her husband. She enjoys reading. Has no history of drug use of alcohol use
Fam Hx: The patient suffers from hypertension, hyperlipidemia, and osteoporosis. She lost her husband of 57 years to a stroke 4 years ago.
Surgical Hx: No history of surgery.
Mental Hx: The patient has become so forgetful of late
Violence Hx: No known history of violence or self-harm
Reproductive Hx: The patient is in menopause and not sexually active
ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT:
- Eyes: uses glasses
- Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: No burning on urination, no incontinence .
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: Has osteoporosis
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.
REPRODUCTIVE: In menopause, Not sexually active.
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
O
Physical exam: MS. W is a 67-year old who is oriented to place but disoriented to time. She is alert and oriented to self, daughter, and person. She has clear speech, which is coherent but tangential at times.
Vital signs: BP 120/82 left-arm sitting, pulse rate of 72, Temp 96.8, Respiration 18 non-labored, height 4’7 weight 180 lbs
Psychiatric: Forgetfulness
Diagnostic results: CT head diffuse cerebral atrophy, MMSE-a score of 20 of 30 with primary deficits in orientation, registration, attention, calculation, and recall. CXR- no cardiopulmonary abnormal findings. Normal blood count, sugar low normal, sodium was low normal, potassium was low, cholesterol was low, thyroid was low
A (assessment)
Complete blood count with differential count
Differential diagnoses:
Dementia
Dementia is the priority diagnosis for the patient. Dementia refers to a clinical syndrome, which presents with progressive decline in two or more cognitive domains such as memory, visuospatial function, behavior, personality, and language (Weller & Budson, 2018). Nursing literature indicates that Alzheimer’s disease is the most common cause of dementia, which accounts for approximately 80 percent of dementia diagnoses. The patient’s clinical manifestations indicate that she has been of late forgetful, has been irritable with other people noting personality change, and her MMSE test score was 20 out of 30 with deficits in attention, recall, orientation, registration, and calculation.
Delirium
According to the American Psychiatric Association (2013), the criteria for diagnosing delirium is a disturbance of attention which might include an inability to focus, and reduced orientation to the environment, memory deficit, language, and visuospatial or perception.
Major depressive disorder
Major depressive disorder is a mental health illness where an individual must present with five or more symptoms for 2 weeks. The symptoms are insomnia, depressed mood, loss of pleasure in activities that one enjoyed, agitation, retardation, and weight gain or loss (Giannelli, 2020).
P (plan)
Nursing literature indicates that only two classes of pharmacological agents are available for use for patients diagnosed with dementia. The medications are cholinesterase inhibitors donepezil, galantamine, and rivastigmine (Weller & Budson, 2018).
Reflection
The patient and the family would be advised to follow up with the physician to ensure that the patient’s condition improves while at the same time achieving a high level of functioning.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Jellinger, K. A., & Korczyn, A. D. (2018). Are dementia with Lewy bodies and Parkinson’s disease dementia the same disease?. BMC medicine, 16(1), 1-16.
Giannelli, Frank R. MS, PA-C. Major depressive disorder. Journal of the American Academy of Physician Assistants 33(4):p 19-20, April 2020. | DOI: 10.1097/01.JAA.0000657208.70820.ab