S.T. is an 80-year-old female brought into the clinic by her caregiver for concerns of AMS, back pain, confusion, hallucination, screaming, and falls for the past week. The patient was recently treated for UTI. Care caregiver states the patient had no fever, or chills, and denies coughing, running nose, or chest discomfort, nausea or vomiting. The caregiver states patient had decreased output for the past 1 week. The patient is alert and oriented to self and name calling, skin intact with minor bruises from a fall. BP 98/69, P 52, R 18, T 99.2, pox 94%. PMHx of Anxiety, depression, COPD, HTN, Seizure disorder. Current medication: Gabapentin 300mg, Synthroid 75mcg, Quetiapine 100mg, Divalproex sodium 125mg, and Bupropion 150mg.
What further ROS questions will you want to ask her? List at least three. What physical exam (PE) will you perform on this patient? List at least three.
What are the differential diagnoses that you are considering? (Possible dx Recurrent UTI, Sepsis, Delirium, Dehydration).
Describe at least three (one of them should be the primary dx). What laboratory tests will help you rule out some of the differential diagnoses?
List treatment options: medications with dose, side effects, and/or cautions in the older adult. Write your order in the SOAP note as you would for an actual patient.
What education will you provide for this patient and family. Write least three possible discussion questions/prompts for your audience
Write a focused SOAP note for this case and support with 5 APA reference.
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