Episodic/Focused SOAP Note Template
Patient Information:
C. B, 76, Male, Caucasian.
S.
CC (chief complaint): Forgetfulness and memory loss
HPI: Christ Bush is a 76-year-old Caucasian male with a history of hypertension, Congestive heart failure, GERD, depression, and high cholesterol who came to the clinic with a complain of forgetfulness that started 8 months ago and has progressively got worse. He stated that he doesn’t have any problem with managing his finances or driving but has issues with remembering what he plans to do whenever he goes to next room. He decided to seek for medical attention after he got frustrated for not remembering that he went to his room to take his routine medication. . Patient denies any head trauma or recent fall. No difficulty breathing or any chest pain.
Current Medications:
Hydrochlorothiazide/Lisinopril: 12.5/10 mg daily
Omeprazole: 20 mg daily
Simvastatin: 20 mg Nightly
Bupropion: 100mg daily
Trazadone: 50 mg
Acetaminophen extra strength: 1000mg PRN
Allergies: Penicillin (Hives), Iodine (Rashes), NKFA
PMHx:
Hypertension
Congestive heart failure
Depression
Hyperlipidemia
GERD
Insomnia
Obstructive sleep apnea
Chronic back pain
Last hospitalization was in August 2020 for Pneumonia and fluid overload.
Current in all immunizations. Last tetanus shot was in December 2018. 2 doses Pfizer covid vaccination in March of 2021.
Soc Hx: Patient is currently married to his first love from high school. They have 3 children, 10 grandchildren and 5 great grandchildren. He retired from management position at Walmart distribution. He loves to go on vacation with his wife and attend soccer games with his grandchildren. He walk every evening with his wife around their neighborhood.
No tobacco use
No Alcohol use
Denies any illicit drugs
He visited his primary care provider here at the clinic for annual checkups. Last colonoscopy was 5 years ago. He currently stays alone with his wife and has two dogs. He uses smoke detectors and always apply his seat belt while driving without texting or talking on the phone. He has a good support system and one of his sons leave close to the patient.
Fam Hx:
Mother: deceased at 55 from stroke. Hx of high cholesterol, HTN, DM II,
Father: 97 years with dementia, BPH, HTN, GERD, back pain
Sister: 74, Diabetes, HTN, breast cancer,
Sister: Deceased at 53 from AAA. Hx of high cholesterol, HTN,
Brother: 71, Hx of HTN, insomnia, TIA, CKD stage 4 with current dialysis.
Paternal grandmother and grandfather: Died many years ago with unknown cause or medical issues.
Maternal grandfather and grandmother: Both died from motor vehicle accident, with unknown medical conditions.
ROS:
GENERAL: Denies weight loss, fever, chills, weakness, or fatigue. No acute distress
HEENT: Head denies head trauma
Eyes: Denies visual loss, blurred vision, or double vision
Ears: Denies tinnitus, hearing loss or any discharge
Nose: No rhinorrhea or sneezing
Throat: Denies sore throat.
CARDIOVASCULAR: Denies chest pain, or palpitations.
RESPIRATORY: Denies shortness of breath, cough, or sputum.
NEUROLOGICAL: Recent positive memory loss. Denies headache, numbness, tingling dizziness, or dysphagia. No unilateral weakness.
MUSCULOSKELETAL: Denies muscle stiffness. Chronic back pain.
PSYCHIATRIC: History of depression with no current distress. Denies suicidal ideation.
.
O.
Physical exam:
Vitals: BP 136/88, HR-89, Temp- 98.6, Spo2- 98% RA, RR- 18
GENERAL: A&O X3, no distress noted.
HEENT: Normocephalic, PERRLA, conjunctiva is clear, oronasopharynx is clear. No ear discharge noted
Neck: Trachea midline, No thyromegaly, carotid no bruit.
CARDIOVASCULAR: Regular heart rate/rhythm with no rub or gallop heard. No JVD or carotid bruits noted. Equal bilateral pulses. No edema noted.
RESPIRATORY: Symmetrical chest expansion. Clear lungs with no wheezing or crackles.
NEUROLOGICAL: No sensory or motor deficit. Small short time memory noted.
MUSCULOSKELETAL: No weakness noted. Negative kyphosis.
PSYCHIATRIC: No recent depression or anxiety noted
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Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)
A.
Differential Diagnoses: List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each with evidence literature
.
References
You are required to include evidence-based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.
Episodic/Focused SOAP Note Template
Patient Information:
- B, 76, Male, Caucasian.
S.
CC (chief complaint): Forgetfulness and memory loss
HPI: Christ Bush is a 76-year-old Caucasian male with a history of hypertension, Congestive heart failure, GERD, depression, and high cholesterol who came to the clinic with a complain of forgetfulness that started 8 months ago and has progressively got worse. He stated that he doesn’t have any problem with managing his finances or driving but has issues with remembering what he plans to do whenever he goes to next room. He decided to seek for medical attention after he got frustrated for not remembering that he went to his room to take his routine medication. . Patient denies any head trauma or recent fall. No difficulty breathing or any chest pain.
Current Medications:
Hydrochlorothiazide/Lisinopril: 12.5/10 mg daily
Omeprazole: 20 mg daily
Simvastatin: 20 mg Nightly
Bupropion: 100mg daily
Trazadone: 50 mg
Acetaminophen extra strength: 1000mg PRN
Allergies: Penicillin (Hives), Iodine (Rashes), NKFA
PMHx:
Hypertension
Congestive heart failure
Depression
Hyperlipidemia
GERD
Insomnia
Obstructive sleep apnea
Chronic back pain
Last hospitalization was in August 2020 for Pneumonia and fluid overload.
Current in all immunizations. Last tetanus shot was in December 2018. 2 doses Pfizer covid vaccination in March of 2021.
Soc Hx: Patient is currently married to his first love from high school. They have 3 children, 10 grandchildren and 5 great grandchildren. He retired from management position at Walmart distribution. He loves to go on vacation with his wife and attend soccer games with his grandchildren. He walk every evening with his wife around their neighborhood.
No tobacco use
No Alcohol use
Denies any illicit drugs
He visited his primary care provider here at the clinic for annual checkups. Last colonoscopy was 5 years ago. He currently stays alone with his wife and has two dogs. He uses smoke detectors and always apply his seat belt while driving without texting or talking on the phone. He has a good support system and one of his sons leave close to the patient.
Fam Hx:
Mother: deceased at 55 from stroke. Hx of high cholesterol, HTN, DM II,
Father: 97 years with dementia, BPH, HTN, GERD, back pain
Sister: 74, Diabetes, HTN, breast cancer,
Sister: Deceased at 53 from AAA. Hx of high cholesterol, HTN,
Brother: 71, Hx of HTN, insomnia, TIA, CKD stage 4 with current dialysis.
Paternal grandmother and grandfather: Died many years ago with unknown cause or medical issues.
Maternal grandfather and grandmother: Both died from motor vehicle accident, with unknown medical conditions.
ROS:
GENERAL: Denies weight loss, fever, chills, weakness, or fatigue. No acute distress
HEENT: Head denies head trauma
Eyes: Denies visual loss, blurred vision, or double vision
Ears: Denies tinnitus, hearing loss or any discharge
Nose: No rhinorrhea or sneezing
Throat: Denies sore throat.
CARDIOVASCULAR: Denies chest pain, or palpitations.
RESPIRATORY: Denies shortness of breath, cough, or sputum.
NEUROLOGICAL: Recent positive memory loss. Denies headache, numbness, tingling dizziness, or dysphagia. No unilateral weakness.
MUSCULOSKELETAL: Denies muscle stiffness. Chronic back pain.
PSYCHIATRIC: History of depression with no current distress. Denies suicidal ideation.
.
O.
Physical exam:
Vitals: BP 136/88, HR-89, Temp- 98.6, Spo2- 98% RA, RR- 18
GENERAL: A&O X3, no distress noted.
HEENT: Normocephalic, PERRLA, conjunctiva is clear, oronasopharynx is clear. No ear discharge noted
Neck: Trachea midline, No thyromegaly, carotid no bruit.
CARDIOVASCULAR: Regular heart rate/rhythm with no rub or gallop heard. No JVD or carotid bruits noted. Equal bilateral pulses. No edema noted.
RESPIRATORY: Symmetrical chest expansion. Clear lungs with no wheezing or crackles.
NEUROLOGICAL: No sensory or motor deficit. Small short time memory noted.
MUSCULOSKELETAL: No weakness noted. Negative kyphosis.
PSYCHIATRIC: No recent depression or anxiety noted
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Diagnostic results:
Neuropsychological testing: The initial diagnostic test that should be done on a patient who complains of memory impairment is neuropsychological assessment. The test enables the healthcare professional to obtain objective data that tells the severity of memory impairment (Arlt, 2018). The Mini-Mental State Examination (MMSE) has been administered to assess cognitive function or decline in the client (American Academy of Family Physicians, 2020). The MMSE score indicates moderate to severe cognitive impairment.
Amyloid imaging: This is normally conducted to estimate the brain amyloid burden commonly observed in patients with cognitive impairment. It is done using Pittsburgh compound B (PiB). Results have revealed a binding pattern greater than 60% (Arlt, 2018).
Cerebrospinal fluid (CSF) biomarkers: The contents of cerebrospinal fluid cam tell the type of neurological condition that is causing memory loss and forgetfulness. Diagnostic findings for the patient have revealed increased CSF t-tau and CSF p-tau with decreased CSF Aβ42 (Arlt, 2018).
Cranial magnetic resonance imaging (MRI): Cranial MRI is conducted to examine changes on brain structures. Results have revealed hippocampal atrophy (Arlt, 2018).
Laboratory tests:
Complete Blood Cell Count: This is done to determine changes in blood cell concentrations (American Academy of Family Physician, 2020). From the result, all blood cells are in their normal concentrations.
Thyroid function test: No evidence of thyroid dysfunction.
Urinalysis: No evidence of toxicology.
Serological test: Eosinophils, neutrophils, and other phagocytic cells are in normal levels (American Academy of Family Physicians, 2020).
Psychiatric examination: A psychological examination is necessary to assess the mental functioning of the patient. The Diagnostic and Statistical Manual of mental disorders (DSM-5) has been administered in the current scenario (Clark et al., 2017). Results of the examination have revealed episodic forgetfulness or memory loss. There is also evidence of disorientation with difficulty understanding written communication. No evidence of executive dysfunction as the client has no difficulty handling money and can accomplish activities of daily living. There is no visual hallucination, apathy, sleep disturbance, anxiety, depression, or inappropriate social misconduct (Yoon et al., 2018).
A.
Differential Diagnoses:
Alzheimer’s disease (Primary diagnosis): The most possible diagnosis of the patient’s symptoms in Alzheimer’s disease. Old age above 65 years increases a person’s risk of developing Alzheimer’s disease (National Institute on Aging, 2021). Episodic forgetfulness and memory loss are the primary features of Alzheimer’s disease. Evidence of cognitive decline in Alzheimer’s is disease is further confirmed by forgetfulness that affects medication compliance (Yoon et al., 2018). Diagnostic tests that confirm the disease include; MMSE score indicating moderate to severe cognitive impairment, PiB binding pattern greater than 60%, hippocampal atrophy, increased CSF t-tau and CSF p-tau with decreased CSF Aβ42 (Arlt, 2018).
Vascular disease: Vascular disease normally presents with clinical symptoms that resemble those of Alzheimer’s disease such as forgetfulness and memory loss. However, imaging results often reveal vascular lesions without hippocampal atrophy. The other confirmatory tests for Alzheimer’s disease named above are normally absent in vascular disease (Arlt, 2018).
Age-related cognitive decline: This condition is normally characterized with memory loss only with the absence of all other cognitive symptoms (American Academy of Family Physician, 2020).
Dementia with Lewy body: Symptoms resemble those of Alzheimer’s disease. However, imaging results normally reveal excess intracellular Lewy bodies with α-synuclein in the affected regions of the brain (Arlt, 2018).
Hippocampal sclerosis: Memory loss, forgetfulness, and hippocampal atrophy are normally present in individuals with hippocampal sclerosis. However, the confirmatory tests for Alzheimer’s disease named above are normally absent (Arlt, 2018).
References
American Academy of Family Physicians. (2020). Early diagnosis of dementia. https://www.aafp.org/afp/2001/0215/p703.html.
Arlt, S. (2018). Non-Alzheimer’s disease-related memory impairment and dementia. Dialogues in Clinical Neuroscience, 15(4), 465–473. https://doi.org/10.31887/DCNS.2013.15.4/sarlt
Clark, L. A., Cuthbert, B., Lewis-Fernández, R., Narrow, W. E., & Reed, G. M. (2017). Three Approaches to understanding and classifying mental disorder: ICD-11, DSM-5, and the National Institute of Mental Health’s Research Domain Criteria (RDoC). Psychological Science in the Public Interest, 18(2), 72–145. https://doi.org/10.1177/1529100617727266.
National Institute on Aging. (2021). Alzheimer’s disease fact sheet. https://www.nia.nih.gov/health/alzheimers-disease-fact-sheet