Episodic/Focused SOAP Note: Case Study of Confusion in an Elderly Patient, Assignments of Nursing

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Episodic/Focused SOAP Note Tamara Upchurch BSN, RN, CHPN Master of Science in Nursing, Walden University NRNP 6540: Advanced Practice Care of Frail Elders Dr. Ann Kriebel March 10, 2024

Episodic/Focused SOAP Note Patient Initials: A.P. Age: 70 Gender: Female Race: Caucasian S. CC : “Confusion” more than usual HPI : 70-year-old female presenting to the clinic today with her son with reports of acute confusion (more than usual) and some agitation and restlessness. Son reports that two days ago she began to become more confused and very easily agitated. Yesterday she could not remember where she was in her own home. She has no recent falls or trauma. She denies any dysuria, frequency, or urgency. Three days ago, she was seen by her PCP who increased her HCTZ to 50 mg due to increased blood pressure. Medications :

• Multivitamin one tab PO daily for supplement, self-prescribed 5 years ago (age 65)
• Losartan 50 mg one tab PO daily for hypertension, prescribed 10 years ago (age 60)
• HCTZ 50 mg one tab PO daily for hypertension, increased 3 days ago (ago 70)
• Fish Oil one capsule PO daily for supplement, self-prescribed 5 years ago (age 65)
• Glyburide 5 mg one tab PO daily for type 2 diabetes, prescribed 10 years ago (age 60)
• Metformin 500 mg one tab PO twice a day for type 2 diabetes, prescribed 12 years ago (age 58)
• Donepezil 10 mg one tab PO daily for dementia, prescribed 2 years ago (age 68)
• Alendronate 70 mg one tab PO once a week for osteoporosis, prescribed 3 years ago (age 67) Allergies :
• Atorvastatin – rash
• No latex allergy PMHx :
• Hypertension
• Type 2 Diabetes
• Osteoporosis
• Chronic Allergic Rhinitis
• No surgical history Immunizations :
• Tdap – 01/
• Flu Vaccine – 10/ Soc Hx :
• A.P. is widower who lives with her son. She is a retired teacher. Denies former/present use of tobacco or illicit drugs. She is a former drinker but has been sober for 15 years. She wears her seat belt while riding in the car. Son reports working fire alarms in the home. There are no stairs to the entry of the home and walkways are kept clear and free of rugs. Fam Hx :
• Mother – hypertensive disorder, type 2 diabetes - Sister – depressive disorder, malignant neoplastic disease (died age: 60) - Father – colon cancer, heart disease, (died at age 65) Mental Hx :
• Dementia – treated with Aricept 10 mg daily
• Denies suicidal/homicidal ideations or visual/auditory hallucinations

Chest/Lungs: Symmetrical movement. No dyspnea noted, no use of accessory muscle. Respiratory rate even. No wheezing, rales/crackles, or rhonchi. Breath sounds normal and good air movement. Heart/Peripheral Vascular: S1, S2, RRR. No murmurs. No edema noted. Abdomen: Bowel sounds: normal, active x 4 quadrants. Soft, non-distended, and no CVA tenderness. Neurological: CN 1-XII grossly intact. Speech clear, coherent, tangential at times. Musculoskeletal: Full weight bearing. Motor strength and tone: normal tone, Upper Extremities 5/5, Lower Extremities 5/5. No tics or involuntary movement of muscles. Shuffling gate noted. Hematologic: Negative areas of bleeding. Lymphatics: Negative for head, cervical, inguinal lymphnopathy. Psychiatric: Normal mood easily distracted. Endocrine: Thyroid normal in size, no nodules noted. Reproductive: Deferred. Diagnostic Results:

• CXR – no cardiopulmonary findings. WNL.
• CT Head – diffuse Cerebral Atrophy
• MMSE – Score 18 of 30 with primary deficits in orientation, registration, attention and calculation, and recall. The score suggests moderate dementia.
• HgA1C – 7.2%
• BMP – TEST RESULTS REFERANCE RANGE Glucose 90 65- 99 Sodium 130* 135- 146 Potassium 3.4* 3.5 – 5. Chloride 104 98- 110 Carbon Dioxide 29 19- 30 Calcium 9.0 8.6-10. BUN 20 7- 25 Creatinine 1.0 0.70-1. Glomerular Filtration (eGFR) 77 >or=60 ml/min/1.73m A. Differential Diagnoses:

1. Hyperactive Delirium secondary to hyponatremia – Delirium is multifactorial and is characterized by altered awareness that mainly affects attention, increased agitation and has an abrupt onset (Gogia & Fang, 2023; Ramírez Echeverría et al., 2023). Hyponatremia and hypokalemia are the two major electrolyte abnormalities caused by thiazides (HCTZ) (Filippone et al., 2020). This diagnosis is ruled in with the lab values noted in the BMP, the rapid onset of the confusion and the symptoms of agitation and reduced orientation to her environment.
2. Urinary Tract Infection (UTI) – UTIs are common in elderly adults and symptoms are atypical with delirium or confusion without a fever the most common symptoms making the diagnosis of UTI a difficult task in the elderly (Dutta et al., 2022). Although she denies dysuria, frequency, or urgency this diagnosis could not be ruled out until a UA and CBC are done to rule out infection.

3. Hypokalemia – Hypokalemia is one of the most common disturbances that is usually seen in the clinical practice, more prevalent than hyperkalemia, but most cases are usually mild (Castro & Sharma, 2019). The BMP confirms that A.P. has mild hypokalemia, 3.4 mmol/L. P.
4. Diagnostic testing: a. Labs: CBC, UA with culture if needed, LFTs, Ammonia level, TSH; Recheck BMP in 2 weeks b. Confusion Assessment Method (CAM) – aides in the diagnosis of delirium c. Cornell Scale for Depression in Dementia – screen for depression, score of 6
5. Pharmacological/Nonpharmacological treatment: a. Thoroughly review medication list, determining any meds that can cause delirium or hyponatremia or hypokalemia b. Discontinue HCTZ 50 mg daily and increase Losartan to 100 mg daily c. Discontinue Glyburide 5 mg, on Beers List of Medications d. Add extra salt to one meal a day for the next 7 days to correct hyponatremia e. Potassium 20 mEq 1 tab PO once a day x 3 days
6. Education: Education provided to son on the cause and treatment of delirium; have him monitor blood pressure at home for the next two week and bring log to follow up visit.
7. Referrals: None currently.
8. Follow Up: Patient to follow up at clinic in two weeks Reflection: The case study was helpful in reminding me that it can be difficult to determine delirium from dementia in the elderly population. Even in those elderly patients that have been diagnosis with Dementia, acute changes from their baseline can be delirium that is multifactual. As an Adult Gerontology Nurse Practitioner its important when assessing the elderly population that I remember to be through in my assessment and look at all causes that could be causing increased confusion or agitation in elderly patients. Reference: Castro, D., & Sharma, S. (2019). Hypokalemia. IN StatPearls; Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK482465/ Dutta, C., Pasha, K., Paul, S., Abbas, M. S., Nassar, S. T., Tasha, T., Desai, A., Bajgain, A., Ali, A., & Mohammed, L. (2022). Urinary tract infection induced delirium in elderly patients: A systematic review. Cureus , 14 (12), 1–
9. https://doi.org/10.7759/cureus. Filippone, E. J., Ruzieh, M., & Foy, A. (2020). Thiazide-Associated hyponatremia: Clinical manifestations and pathophysiology. American Journal of Kidney Diseases , 75 (2), 256–264. https://doi.org/10.1053/j.ajkd.2019.07. Gogia, B., & Fang, X. (2023). Differentiating delirium versus dementia in the elderly. IN StatPearls; Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK570594/