NRNP 6540 Week 2 SOAP Note | Advance Practice Care of Frail Elders.

NRNP 6540 Week 2 SOAP Note | Advance Practice Care of Frail Elders. History of Present Illness (HPI): BW is a 67 YO, female, AA who is brought in today by her daughter with increased forgetfulness, confusion, lack of short-term memory and inappropriate laughing which has gotten progressively worse recently. She has a history of hypertension, hyperlipidemia, and osteoporosis which are controlled with medication. She denies any vision changes, dizziness, headaches, or vertigo. She reports osteoporosis but denies pain able to ambulate without assistance or medical devices. She denies any pain traveling down her legs. She does report that her pain is increased with activity. She reports her pain as 2/10 on the numeric pain scale. She denies any fever, chills, nausea, vomiting, pain with urination, hematuria, foul smelling urine, urinary frequency or urgency. BW 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