Episodic/Focused SOAP Note Template
Initials: C.M., Age: 70, Sex: Female, Race: White
CC (leading sickness): The resigned introduces delay the proviso of disremembrance that makes her learn what she had bybygone to pluck in the introduce extent.
HPI: C.M. is a 70-years old resigned introduces delay instance of disremembrance that has definiteed for a duration of 1 year. The proviso has been worsening delay opportunity and recently she declares that she could go to the introduce extent true to verify that she cannot mind what she went to do. The resigned reverberation though declares that she was tranquil powerful to push out her natural choirs affect performing driving herself and managing her finances. The resigned’s extraction has noticed the residence.
Onset: 1 year ago
Character: Forgetfulness, condensed promise disremembrance that makes her learn condensed promise activities.
Associated signs and symptoms: loathing, vomiting, photophobia, phonophobia
Timing: This occurs unintermittently and seems to be worsening delay opportunity.
Severity: 6/10 disremembrance scale
Current Medications: The resigned has been using Rivastigmine refuse for the definite three months, 1.5 mg orally twice integral day for the moderate two weeks, then she continued delay 3mg twice integral day for the introduce two weeks and and she is currently using 4.5mg twice each day (Khachaturian, & Radebaugh, (Eds.), 2019).
Allergies: No commemorative allergic reactions to either aid or any other pith.
PMHx: The definite tetanus immunization bound was commemorative to be 5th of January 2020. The resigned declares no notorious surgical proceeding manufactured to them in the definite few years. She implied that she was diagnosed delay hypertension when she was 40 and she was powerful to manipulate the proviso and by the age of 42 she was manifest clear from hypertension. She reverberations no immaterial singularity anteriorly the biased singularity for the operative proviso.
Soc Hx: Lifestyle is one of the most sharp contributing circumstanceors to the bloom of a resigned (Dubois, et al. 2016). Beorigin the the resigned introduceed is 70 years old, she has a loftier predominance to constant bloom provisos. The harvest of biased measures that would be further efficacious in the curb of the biased provisos. C.M. reverberations never smoking but reverberations that she used to swallow betwixt the age of 25 to 40 years old when she was diagnosed of eminent lineage influence when she stopped swallowing. C.M. enjoys publicate and she used to go swimming integral day anteriorly her wife passed abthoroughfare one and half years ago. She confirms that she endow it reserved to feed delayout him. She is a Christian and she seeks comfort in the pavilion when she feels only. Two of her manifestation feed delayin the city and one of them visits her constantly. She casually talks delay one of the manifestation who feeds in another aver.
Fam Hx: The identification of the resigned bloom provisos co-operates to ameliorate construction of the potential introduce bloom proviso (Li, et al. 2019). In the instance of C.M. her senior died ten years ago owing of dementia succeeding various years of denial from hypertension and diabetes. Her mother died of a thoroughfare clothing when she was 30 years old. All her siblings are tranquil existing. The eldest is 74 years old and has been diagnosed delay meek dementia. The other two are younger than her and do not enjoy any bloom proviso.
GENERAL: lost 5 pounds in the definite five months, efficacious self-expression, minds her bound of extraction, today’s bound and month, she mass herself to the address. Forgets some of the connective expression and took opportunity to resumption the designate of her younger sister’s designate until her daughter reminds her.
HEENT: Eyes: Blurred expectation for longer regions. Ears: No hearing missing, Nose; No general nose nor sneezing. Throat: No piercing throats and no congestions.
SKIN: No obvious adventurous and reverberationed no longing.
CARDIOVASCULAR: No obvious edema on palpation, chest reservedies nor chest self-denial, chest
RESPIRATORY: No sputum, no animated reservedies and no probe abnatural probe manufactured during animated.
GASTROINTESTINAL: no diarrhea commemorative and no vomiting, reverberationed no loathing nor anorexia. No lineage stains on the stool and no reverberationed abdominal self-denial.
GENITOURINARY: Burning on urination. Pregnancy. Definite menstrual duration, MM/DD/YYYY.
NEUROLOGICAL: difficulty forthcoming uncompounded instructions, learnting the contexts of the next preceding confabulation. No paralysis, no headache and no dizziness nor syncope.
MUSCULOSKELETAL: Minor slowed muscle tally when established up from sitting be, Slight cacophony reverberationed on the muscles, No end self-denial, articulation self-denial
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No bountiful nodes. No circumstance of splenectomy.
PSYCHIATRIC: meek valley succeeding losing her wife.
ENDOCRINOLOGIC: No polyuria nor polydipsia, No reverberations of sweating, apathetic or intensity prejudice.
ALLERGIES: No circumstance of allergic reactions such as asthma.
GENERAL: Physically conscientious and fit when she stands, efficacious self-expression, abundant harangue, no reverberationed self-denial in any part of the collection, 64 kgs, 5’3 ft, efficacious eye inspection for her age, minds her bound of extraction, today’s bound and month, she mass herself to the address. Forgets some of the connective expression and took opportunity to resumption the designate of her younger sister’s designate until her daughter reminds her.
HEENT: Eyes: Blurred expectation for longer interspace objects.
MUSCULOSKELETAL: Minor slowed muscle tally when established up from sitting be, Slight cacophony reverberationed on the muscles, she too does not stalk direct when stalking opposing an disclosed extent.
Diagnostic results: The singularity for immaterial provisos may be carried out by testing lineage to designate administration out the potential suit of the proviso. Lineage tests declare disclaiming for vitamin deficiencies and thyroid guess-work proviso.
Psychotic guess-works: This proviso is considered as one of the differential singularity beorigin that the resigned declares disremembrance.
Anxiety guess-work: This proviso is too considered due to circumstance that the resigned experiences disremembrance for niggardly promises and designates of mob and items.
Alzheimer’s Disease: The deficient expectation, the deficient measure when morning up and when stalking opposing the disclosed extent too co-operate to the choice of this proviso as one of the potential differential singularity (Dubois, et al. 2016).
Dubois, B., Padovani, A., Scheltens, P., Rossi, A., & Dell’Agnello, G. (2016). Timely singularity for Alzheimer’s indisposition: a attainment resurvey on benefits and challenges. Journal of Alzheimer's indisposition, 49(3), 617-631.
Khachaturian, Z. S., & Radebaugh, T. S. (Eds.). (2019). Alzheimer's indisposition: suit (s), singularity, composition, and concern. CRC Press.
Li, M., Yue, L., Gong, X., Li, J., Ji, H., & Asoke, N. (2019). Hierarchical Feature Extraction for Early Alzheimer’s Indisposition Diagnosis.