Soap

Episodic/Focused SOAP Note Template

Patient Information:

Initials: C.M.,  Age: 70, Sex: Female, Race: White

S.

CC (chief complaint): The patient presents with the condition of forgetfulness that makes her forget what she had gone to pick in the next room.

HPI: C.M. is a 70-years old patient presents with case of forgetfulness that has lasted for a period of 1 year. The condition has been worsening with time and lately she indicates that she could go to the next room just to realize that she cannot remember what she went to do. The patient report though indicates that she was still able to carry out her normal choirs like performing driving herself and managing her finances. The patient’s family has noticed the situation.

Location: head

Onset: 1 year ago

Character: Forgetfulness, short term forgetfulness that makes her forget short term activities.

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: This occurs continuously and seems to be worsening with time.

Severity: 6/10 forgetfulness scale

Current Medications: The patient has been using Rivastigmine drug for the last three months, 1.5 mg orally twice every day for the initial two weeks, then she continued with 3mg twice every day for the next two weeks and and she is currently using 4.5mg twice each day (Khachaturian, & Radebaugh, (Eds.), 2019).

Allergies: No recorded allergic reactions to either food or any other substance.

PMHx: The last tetanus immunization date was recorded to be 5th of January 2020. The patient indicates no known surgical procedure done to them in the last few years. She indicated that she was diagnosed with hypertension when she was 40 and she was able to manage the condition and by the age of 42 she was declared free from hypertension. She reports no mental diagnosis before the specific diagnosis for the prevailing condition.

Soc Hx: Lifestyle is one of the most crucial contributing factors to the health of a patient (Dubois, et al. 2016). Considering the the patient presented is 70 years old, she has a higher prevalence to chronic health conditions. The development of specific measures that would be more effective in the control of the specific conditions. C.M. reports never smoking but reports that she used to drink between the age of 25 to 40 years old when she was diagnosed of high blood pressure when she stopped drinking. C.M. enjoys adventure and she used to go swimming every day before her husband passed away one and half years ago. She confirms that she found it difficult to live without him. She is a Christian and she seeks solace in the church when she feels lonely. Two of her children live within the city and one of them visits her frequently. She rarely talks with one of the children who lives in another state.

Fam Hx: The identification of the patient health conditions contributes to better understanding of the possible present health condition (Li, et al. 2019). In the case of C.M. her father died ten years ago because of dementia after several years of suffering from hypertension and diabetes. Her mother died of a road accident when she was 30 years old. All her siblings are still alive. The eldest is 74 years old and has been diagnosed with mild dementia. The other two are younger than her and do not have any health condition.

ROS:

GENERAL:  lost 5 pounds in the last five months, effective self-expression, remembers her date of birth, today’s date and month, she drove herself to the facility. Forgets some of the connective words and took time to recall the name of her younger sister’s name until her daughter reminds her.

HEENT:  Eyes:  Blurred vision for longer regions.  Ears: No hearing loss, Nose; No running nose nor sneezing. Throat: No sore throats and no congestions.

SKIN:  No visible rash and reported no itching.

CARDIOVASCULAR: No visible edema on palpation, chest difficulties nor chest pain, chest

RESPIRATORY:  No sputum, no breathing difficulties and no sound abnormal sound produced during breathing.

GASTROINTESTINAL: no diarrhea recorded and no vomiting, reported no nausea nor anorexia. No blood stains on the stool and no reported abdominal pain.

GENITOURINARY:  Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL:  difficulty following simple instructions, forgetting the contexts of the immediate previous conversation. No paralysis, no headache and no dizziness nor syncope.

MUSCULOSKELETAL:  Minor slowed muscle response when standing up from sitting position, Slight stiffness reported on the muscles, No back pain, joint pain

HEMATOLOGIC:  No anemia, bleeding or bruising.

LYMPHATICS:  No enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  mild depression after losing her husband.

ENDOCRINOLOGIC:   No polyuria nor polydipsia, No reports of sweating, cold or heat intolerance.

ALLERGIES:  No history of allergic reactions such as asthma.

O.

Physical exam:

GENERAL: Physically upright and fit when she stands, effective self-expression, fluent speech, no reported pain in any part of the body, 64 kgs, 5’3 ft, effective eye sight for her age, remembers her date of birth, today’s date and month, she drove herself to the facility. Forgets some of the connective words and took time to recall the name of her younger sister’s name until her daughter reminds her.

HEENT:  Eyes:  Blurred vision for longer distance objects.

MUSCULOSKELETAL: Minor slowed muscle response when standing up from sitting position, Slight stiffness reported on the muscles, she also does not walk straight when walking across an open room.

Diagnostic results: The diagnosis for mental conditions may be carried out by testing blood to determine rule out the possible cause of the condition. Blood tests indicate negative for vitamin deficiencies and thyroid disorder condition.

A.

Differential Diagnoses

Psychotic disorders: This condition is considered as one of the differential diagnosis considering that the patient indicates forgetfulness.

Anxiety disorder: This condition is also considered due to fact that the patient experiences forgetfulness for common terms and names of people and items.

Alzheimer’s Disease: The poor vision, the poor gait when waking up and when walking across the open room also contribute to the selection of this condition as one of the possible differential diagnosis (Dubois, et al. 2016).

References

Dubois, B., Padovani, A., Scheltens, P., Rossi, A., & Dell’Agnello, G. (2016). Timely diagnosis for Alzheimer’s disease: a literature review on benefits and challenges. Journal of Alzheimer’s disease49(3), 617-631.

Khachaturian, Z. S., & Radebaugh, T. S. (Eds.). (2019). Alzheimer’s disease: cause (s), diagnosis, treatment, and care. CRC Press.

Li, M., Yue, L., Gong, X., Li, J., Ji, H., & Asoke, N. (2019). Hierarchical Feature Extraction for Early Alzheimer’s Disease Diagnosis.