SUBJECTIVE- History
Chief Complaint: Altered Mental Status. “Patient has been especially drowsy and can
barely answer commands.” –Staff member
HPI:
76 YO ECF Hispanic male with new onset altered mental status that st
...
SUBJECTIVE- History
Chief Complaint: Altered Mental Status. “Patient has been especially drowsy and can
barely answer commands.” –Staff member
HPI:
76 YO ECF Hispanic male with new onset altered mental status that started
approximately 2 hours after a dose of Percocet. The staff report he opens his eyes
inconsistently to command and does not reliably respond to verbal stimuli. Staff
denied recent facility fall or trauma, but has a + history of seizures and diabetes.
This AMS started approximately 30 minutes ago and is worsening (patient becoming
more lethargic). The staff report that he did eat his morning meal and received a
dose of insulin to cover an elevated BG. According to family, the patient has not taken
Percocet in the past.
Social Hx:
Tobacco: never used
Alcohol: former drinker
Drug use: denies street drug use
Lives with wife
Smoke detector in the house: yes
Language: English No travel outside US
Current Medications:
Amlodipine 5mg tablet, once per day
Aspirin 81mg, once per day
Bisacodyl 10mg suppository. Insert once daily PRN for constipation
Carvedilol 3.125mg tablet, BID with meals
Clopidogrel 75mg tablet once daily
Daily Multivitamin tablet
Divalproex 500mg EC tablet, once daily
Docusate Sodium 100mg capsule, twice daily for 30 days
Ferrous Sulfate 325mg tablet, take once per day with breakfast for 30 days
Gabapentin 300mg capsule, once daily
Hydrocodone Acetaminophen 5-325 mg per tablet, take 1 tab every 4 hours PRN for
pain
Insulin Glargine 100unit/mL insulin pen, inject 15 units nightly for 30 days
Insulin Lispro 100unit/mL insulin pen, inject 1-10 units 3 times per day with meals
for 30 days
Insulin Lispro 100unit/mL insulin pen, inject 1-8 units nightly for 30 days
Lipitor 40mg tablet, once daily
[Show More]
![Preview image of [SOLVE]MBSOAP Note #2 N6320. document](https://www.scholarfriends.com/storage/MBSOAP_Note__2_N6320.png)
