Alzheimer’s disease Soap Note

ALZHEIMER’S DISEASE SOAP NOTE 2 PATIENT INFORMATION NAME: C. M AGE: 70 years SEX: Female SOURCE: Patient ALLERGIES: NKDA CURRENT MEDICATIONS: None PMHX: Patient confirms history of Down syndrome; patient confirms history of osteoporosis; confirms past hospitalization because of an accident; confirms past head trauma as a result of the accident; denies blood transfusion hx FAMHX: Father had a history of hypertension; mother’s hx is positive for Alzheimer’s disease; patient has two children in good health SOHX: Patient denies alcohol consumption of use of recreational drugs; patient stays at home with husband; grandchildren come to visit occasionally IMMUNIZATIONS: All immunizations up-to-date This study source was downloaded by from CourseH on :13:46 GMT -05:00 ALZHEIMER’S DISEASE SOAP NOTE 3 SUBJECTIVE: CC: Patient comes to the clinic and verbalizes, “I have a problem with my memory. I seem to forget recent events and I have difficulty organizing my thoughts”. S: HPI: A 70-year-old man visits the clinic with complaints of problems with memory. She seems to forget recent events in her life and has great difficulty organizing her thoughts. AAlso, patient states that she repeats statements and questions over and over even after making the statements before. He has also been forgetting conversations and appointments. She often misplaces her possessions and has gotten lost two times in the neighborhood. She also reports difficulty concentrating and thinking. Patient also finds it difficult to multi-task and she finds it extremely difficult to respond to the daily problems. She has also been experiencing changes in personality and behavior including aspects such as depression, social withdrawal, mood swings, apathy, changes in sleeping habits, and delusions. She denies fever, vomiting, constipation, and diarrhea. ROS: CONSTITUTIONAL: Patient seems to be far in though. She seems to lose track of our discussion and does not seem to concentrate. She forgets so fast and looks withdrawn Head: Confirms hx head trauma Skin: Patient denies skin rashes; denies dry or scaly skin Eyes: Confirms change in vision; confirms use of corrective lenses to focus Ears: Denies drainage Nose: Denies congestion; denies stuffy nose This study source was downloaded by from CourseH on :13:46 GMT -05:00 ALZHEIMER’S DISEASE SOAP NOTE 4 Mouth/Throat: Denies sores in the mouth or tongue; denies dental bleeding or pain; denies sore throat Neck: Denies pain in the neck Cardiovascular: Denies missing beats or irregular pulse Respiratory: Denies pain on inspiration and expiration Gastrointestinal: Patient denies nausea, vomiting Musculoskeletal: Denies joint or muscle pain; denies stiffness OBJECTIVE: CONSTITUTIONAL: Temperature 97.6; Pulse 68; Respirations 18; BP 145/65; Height 6’ 14’’; BMI 25.62; Weight 140 lbs Lungs: No rales or rhonchi Cardiovascular: S1 and S2 normal; extremities are dry