[SOLVE]MBSOAP Note #2 N6320.

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