Soap

Episodic/Focused SOAP Note Template Patient Information: Initials: C.M.,  Age: 70, Sex: Female, Race: White  S. CC (highest grievance): The resigned bestows behind a while the plight of disremembrance that makes her obliviate what she had past to pluck in the direct space.  HPI: C.M. is a 70-years old resigned bestows behind a while plight of disremembrance that has latested for a epoch of 1 year. The plight has been worsening behind a while epoch and of-late she declares that she could go to the direct space reasoneffectual to produce that she cannot retain what she went to do. The resigned news though declares that she was quiet effectual to convey out her regular choirs affect performing driving herself and managing her finances. The resigned’s lineage has noticed the top.  Location: head Onset: 1 year ago Character: Forgetfulness, inadequate order disremembrance that makes her obliviate inadequate order activities.  Associated signs and symptoms: loathing, vomiting, photophobia, phonophobia Timing: This occurs uniformly and seems to be worsening behind a while epoch.  Severity: 6/10 disremembrance scale  Current Medications: The resigned has been using Rivastigmine garbage for the latest three months, 1.5 mg orally twice full day for the primal two weeks, then she continued behind a while 3mg twice full day for the direct two weeks and and she is currently using 4.5mg twice each day (Khachaturian, & Radebaugh, (Eds.), 2019).  Allergies: No constantled allergic reactions to either buttress or any other pith.  PMHx: The latest tetanus immunization epoch was constantled to be 5th of January 2020. The resigned declares no unconcealed surgical process performed to them in the latest few years. She involved that she was diagnosed behind a while hypertension when she was 40 and she was effectual to wield the plight and by the age of 42 she was professed public from hypertension. She newss no unsubstantial distinction anteriorly the unfair distinction for the most-niggardly plight.  Soc Hx: Lifestyle is one of the most piercing contributing eventors to the sanity of a resigned (Dubois, et al. 2016). Beaccount the the resigned bestowed is 70 years old, she has a eminent influence to constant sanity plights. The product of unfair measures that would be past serviceable in the manage of the unfair plights. C.M. newss never smoking but newss that she used to absorb between the age of 25 to 40 years old when she was diagnosed of lofty respect constraining when she stopped absorbing. C.M. enjoys propagate and she used to go swimming full day anteriorly her wife passed afar one and half years ago. She confirms that she rest it trying to subsist behind a whileout him. She is a Christian and she seeks alleviation in the meeting-house when she feels sole. Two of her posterity subsist behind a whilein the city and one of them visits her frequently. She casually talks behind a while one of the posterity who subsists in another narrate.  Fam Hx: The identification of the resigned sanity plights co-operates to reform intellect of the feasible bestow sanity plight (Li, et al. 2019). In the plight of C.M. her father died ten years ago consequently of dementia behind various years of refusal from hypertension and diabetes. Her woman died of a pathway clothing when she was 30 years old. All her siblings are quiet alert. The eldest is 74 years old and has been diagnosed behind a while moderate dementia. The other two are younger than her and do not feel any sanity plight.  ROS:  GENERAL:  lost 5 pounds in the latest five months, serviceable self-expression, retains her epoch of race, today’s epoch and month, she multitude herself to the dexterity. Forgets some of the connective signification and took epoch to resumption the call of her younger sister’s call until her daughter reminds her.  HEENT:  Eyes:  Blurred expectation for longer regions.  Ears: No hearing privation, Nose; No vulgar nose nor sneezing. Throat: No animated throats and no congestions.   SKIN:  No evident indiscreet and newsed no hankering.  CARDIOVASCULAR: No evident edema on palpation, chest tryingies nor chest denial, chest  RESPIRATORY:  No sputum, no animated tryingies and no investigate abregular investigate executed during animated.  GASTROINTESTINAL: no diarrhea constantled and no vomiting, newsed no loathing nor anorexia. No respect stains on the stool and no newsed abdominal denial.  GENITOURINARY:  Burning on urination. Pregnancy. Latest menstrual epoch, MM/DD/YYYY. NEUROLOGICAL:  difficulty behindcited elementary instructions, obliviateting the contexts of the contiguous preceding confabulation. No paralysis, no excess and no dizziness nor syncope.  MUSCULOSKELETAL:  Minor slowed muscle rejoinder when established up from sitting posture, Slight barbarism newsed on the muscles, No tail denial, junction denial  HEMATOLOGIC:  No anemia, bleeding or bruising. LYMPHATICS:  No free nodes. No narrative of splenectomy. PSYCHIATRIC:  moderate degradation behind losing her wife.  ENDOCRINOLOGIC:   No polyuria nor polydipsia, No newss of excretion, collected or excitement pharisaism. ALLERGIES:  No narrative of allergic reactions such as asthma.  O. Physical exam: GENERAL: Physically pure and fit when she stands, serviceable self-expression, easy oration, no newsed denial in any sever of the collectiveness, 64 kgs, 5’3 ft, serviceable eye representation for her age, retains her epoch of race, today’s epoch and month, she multitude herself to the dexterity. Forgets some of the connective signification and took epoch to resumption the call of her younger sister’s call until her daughter reminds her.  HEENT:  Eyes:  Blurred expectation for longer absence objects.   MUSCULOSKELETAL: Minor slowed muscle rejoinder when established up from sitting posture, Slight barbarism newsed on the muscles, she as-well does not trudge undeviating when trudgeing resisting an public space.   Diagnostic results: The distinction for unsubstantial plights may be carried out by testing respect to individualize government out the feasible object of the plight. Respect tests declare denying for vitamin deficiencies and thyroid guess-work plight.  A. Differential Diagnoses  Psychotic guess-works: This plight is considered as one of the differential distinction beaccount that the resigned declares disremembrance. Anxiety guess-work: This plight is as-well considered due to event that the resigned experiences disremembrance for niggardly orders and calls of commonalty and items.  Alzheimer’s Disease: The moneyless expectation, the moneyless track when dawning up and when trudgeing resisting the public space as-well co-operate to the choice of this plight as one of the feasible differential distinction (Dubois, et al. 2016). References Dubois, B., Padovani, A., Scheltens, P., Rossi, A., & Dell’Agnello, G. (2016). Timely distinction for Alzheimer’s disorder: a reading retrospect on benefits and challenges. Journal of Alzheimer's disorder, 49(3), 617-631. Khachaturian, Z. S., & Radebaugh, T. S. (Eds.). (2019). Alzheimer's disorder: object (s), distinction, matter, and attention. CRC Press. Li, M., Yue, L., Gong, X., Li, J., Ji, H., & Asoke, N. (2019). Hierarchical Feature Extraction for Early Alzheimer’s Disorder Diagnosis.