Focused SOAP Note
Focused SOAP Note
Initials: Ms. W Age: 67 Sex: Female Race: African American
CC (chief complaint): Concerns of forgetfulness.
HPI (history of present illness): Ms. Washington is a 67-year-old African American female who is brought to your office by her daughter with concerns of “forgetfulness.” She has lived with her daughter for 4 years now, and her daughter reports noticing she asks the same questions even after they have been answered. She even reports her mom getting lost in Walmart recently. Ms. Washington has lived with her daughter since losing her husband of 57 years, about 4 years ago. Her daughter states her mother is a retired teacher and usually very astute but notices more forgetfulness. According to Ms. Washington’s daughter, Angela, her mom has been demonstrating increased forgetfulness of more recent things but can easily recall historical moments and events. She also reports that sometimes her mom has difficulty “finding the right words” in a conversation, and then will shift to an entirely different line of conversation. She also said her mother will “laugh off” things when she forgets important appointments and/or become upset or critical of others who try to point these things out.
• Amlodipine 10mg daily
• HCTZ 12.5mg daily
• Multivitamin daily
• Atorvastatin 40mg daily
• Alendronate 70mg orally once a week
Allergies: Penicillin: rash, Lisinopril: cough.
PMHx: Hypertension, Hyperlipidemia, Osteoporosis
Soc and Substance Hx: Lives with the daughter since losing her husband of 57 years 4 years ago. She is a retired teacher. No history of tobacco or alcohol use. She has lived with the daughter for 4 years.
Fam Hx: She has been married for 57 years. Her husband died 4 years. The cause of death is unknown. The health of the daughter is insignificant.
Surgical Hx: No history of prior surgical procedures.
Mental Hx: The patient has a history of forgetfulness. The daughter recalls she recently got lost in Walmart. Ms. Washington scores 18 out of 30 with primary deficits in orientation, registration, attention and calculation, and recall.
Violence Hx: No history of personal, home, or sexual violence.
Reproductive Hx: She is 67 years and past menstruating age. No history of sexual intercourse since the death of her husband.
ROS (review of symptoms):
• General: No weakness, fever, chills, body weight loss or gain.
• Head: No history of trauma or impact.
• EENT (eyes, ears, nose, and throat): No visual loss or double vision, no hearing loss or discharge, no nasal discharge or congestion, and no sore throat.
• Cardiovascular: No history of edema, pain, or pressure.
• Respiratory: No shortness of breath.
• Gastrointestinal: No nausea, vomiting, abdominal pain, diarrhea, or constipation.
• Genitourinary: No history of nocturia, dysuria, breast or cervical cancer. Postmenopausal.
• Musculoskeletal: No history of joint or muscle pain, falling or osteoporosis.
• Neurological: No history of headache, dizziness, or numbness.
• Hematologic: No history of bleeding or anemia.
• Lymphatics: No enlarged nodes. No history of splenectomy.
• Psychiatric: No history of depression, anxiety, or hallucinations. Patient has a recent history of forgetfulness.
• Endocrinologic: No history of diabetes, heat or cold intolerance.
• Reproductive: Postmenopausal. No vaginal discharge.
• Allergies: Penicillin: rash, Lisinopril: cough.
General: Ms. Washington is a 67-year-old female who is alert, cooperative with today’s clinical interview. Her eye contact is fair. Speech is clear and coherent but tangential at times. She makes no unusual motor movements and demonstrates no tics. She denies any visual or auditory hallucinations. She denies any suicidal thoughts or ideations. She is alert and oriented to person, partially oriented to place but is disoriented to time and place. (She reported that she thought was headed to work but “wound up here,” referring to your office, at which point she begins to laugh it off.) She denies any falls or pain.
Vital signs: 98.2 124/74 HR-72 20
General: A&O *3 NAD and appropriately dressed.
HEENT: Intact facial sensation. Pupil equal and around and reactive to light. Ears are symmetrical and no discharge. Nose are symmetrical and no nasal polyps. No erythema on the throat. Neck is supple with no tracheal deviation.
Chest/Lungs: CTA AP&L.
Heart/Peripheral Vascular: RRR without a murmur, rub, gallop, pulses +2.
Abdomen: Diffuse, or rebound.
Musculoskeletal: Symmetric muscle development and no falls reported.
Neurological: CN I-IV grossly in intact as well as pain sensation intact
Skin: No bruises, plaques, or hemorrhage.
1. CXR—no cardiopulmonary findings. WNL
2. CT head—diffuse Cerebral Atrophy
Ms. Washington scores 18 out of 30 with primary deficits in orientation, registration, attention and calculation, and recall. The score suggests moderate dementia.
F03. 90 Moderate dementia
Dementia is a group of symptoms that affect memory, thinking patterns, and social abilities that interfere with the daily life activities of an individual. One of the major indicators of dementia is memory loss (Lamb et al., 2018). Memory loss affects the ability to partake in daily activities. Although there is no cure for dementia, medications and therapy can prevent deterioration of the condition (Lamb et al., 2018). Patients require immediate treatment to enhance their capacity to perform daily activities.
G30. 9 Alzheimer’s disease, unspecified
Alzheimer’s disease is a degenerative that disables the nervous system leading to dementia or memory loss of recent activities. The disease can cause death or incapacitation (Weller & Budson, 2018). The cause of Alzheimer’s disease is not known although scientists argue that it is a result of a combination of diseases. The disease can occur in different levels including Early-Onset, Late-Onset, and Familial (Weller & Budson, 2018). One of the medications approved for Alzheimer’s disease is Aducanumab. The medication is used to reduce amyloid plaques that are associated with the disease.
G20 Parkinson’s disease
Parkinson’s disease is a condition that starts by affecting the physical parts of the body causing shakiness, stiffness and walking difficulty (Ball et al., 2019). The condition deteriorates to cause cognitive challenges causing forgetfulness and difficulty in concentration (Ball et al., 2019). The disease can worsen to cause dementia. The condition leads to profound memory loss and difficulty in maintaining relationships.
F32. 9 Major depressive disorder, single episode, unspecified
Major depressive disorder causes persistent sadness and loss of interest in daily activities (Kennis et al., 2020). Clinical depression causes an affect in how people feel, think, or behave. Depression is associated with forgetfulness and confusion (Kennis et al., 2020). Patients with depression can forget basic issues such as directions. It causes an effect in the flow of a conversation.
The patient has a mental problem that requires both a combination of medical and non-medical conditions. Donepezil (Aricept) is the common treatment for different stages of dementia (Lamb et al., 2018). Rivastigmine (Exelon) is approved for treatment of mild to moderate levels of the disease. The patient should take the medication and report after two weeks for further evaluation. Psychotherapeutic interventions are necessary to help the patient understand feelings of sadness or anger and prescribe medication to address the disease (Lamb et al., 2018). The focus of the treatment is to address the changes in mood and behavior.
The patient can join a support group for other elderly people. The support groups will help the patient to understand other people are going through similar incidents (Lamb et al., 2018). The support will provide cushion for the patient to manage the condition effectively.
The patient should come back for review after two weeks. It will be important for the sister to take precaution to ensure the mother is not lost in the public buildings again. The daughter should monitor the behavior to identify any changes.
The case study shows that patients can have different symptoms. A practitioner has a responsibility to provide care to the patient using professional standards. It is vital to take care of the patients by carrying out a thorough assessment. One of the observations is that the patient could be suffering from the loss of the husband. There is no history of mental illness in the family and the condition has been deteriorating since the death of the husband. Appropriate treatment interventions are critical in the care for the patient. The patient requires social support such as a person who can accompany her to the clinic or public places such as supermarket. Early interventions of the condition will improve the quality of life of the patient and prevent adverse outcomes.
Ball, N., Teo, W. P., Chandra, S., & Chapman, J. (2019). Parkinson’s disease and the environment. Frontiers in neurology, 10, 218.
Kennis, M., Gerritsen, L., van Dalen, M., Williams, A., Cuijpers, P., & Bockting, C. (2020). Prospective biomarkers of major depressive disorder: a systematic review and meta-analysis. Molecular psychiatry, 25(2), 321-338.
Lamb, S. E., Sheehan, B., Atherton, N., Nichols, V., Collins, H., Mistry, D., … & Lall, R. (2018). Dementia And Physical Activity (DAPA) trial of moderate to high intensity exercise training for people with dementia: randomised controlled trial. bmj, 361.
Weller, J., & Budson, A. (2018). Current understanding of Alzheimer’s disease diagnosis and treatment. F1000Research, 7.