Focused SOAP Note

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The University of Nairobi *

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HEALTH ASS

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Nursing

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Nov 24, 2024

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docx

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Focused SOAP Note Student’s Name Institutional Affiliation Course Name Instructor’s Name Date

Focused SOAP Note Patient Information: Initials: MC, Age: 68, Sex: Female, Race: Not specified S (Subjective): Chief Complaint (CC): “ Recent memory loss is worrying me. I'm here because my daughter Amanda realized I keep asking the same questions after she's answered them. I got lost in Walmart recently, which worried me, she says. It seems like my forgetfulness is becoming worse. Sometimes I joke off my inability to find the perfect words in a discussion, but it disturbs me. Amanda claims I forget crucial appointments and am critical when reminded. Sometimes I'm not sure where I am, which is strange.” History of Present Illness (HPI): The 68-year-old African American Ms. Carter has a history of growing forgetfulness, particularly regarding recent occurrences. As the patient's husband died, her cognitive decline lasted four years. Her daughter, the primary caretaker, noticed her amnesia as it became more noticeable. The patient sometimes struggles to find the correct words during conversations due to forgetfulness. Persistence and communicative impact make this issue important. Ms. Carter's daughter notices that the patient frequently changes topics mid-conversation, indicating a problem with coherence and focus. The emotional response of Ms. Carter to her forgetfulness is concerning. The daughter laughs or dismisses essential details when she forgets them, suggesting a coping mechanism or emotional response to cognitive obstacles. These symptoms' steady course raises issues about their genesis and need a thorough assessment to identify the best diagnosis and treatment. . Current Medications:

1. Amlodipine 10mg daily 2. HCTZ 12.5mg daily 3. Multivitamin daily 4. Atorvastatin 40mg daily 5. Alendronate 70mg orally once a week Allergies: Penicillin, Lisinopril Past Medical History (PMH): Hypertension, Hyperlipidemia, Osteoporosis Social History: For four years, retired teacher Ms. Carter has lived with her daughter. Throughout her teaching career, she has participated in community educational and social events. During her retirement, she has prioritized time with her family, especially her daughter, who is her primary caregiver. Ms. Carter has strong social connections from growing up in a close-knit area. She participated in community events, groups, and volunteering to promote education. She promotes community and intellectual interchange by sharing her knowledge and experiences as a retired teacher. The previous four years living with her daughter have changed Ms. Carter's routines and social connections. She once balanced career and domestic duties, but her husband's death changed that. As the primary caregiver, her daughter cares for Ms. Carter and provides emotional support. Now, Ms. Carter's social network is mostly family and local friends. Despite her cognitive issues, she maintains relationships with people who understand her. Ms. Carter's emotional resilience depends on this social support network. Ms. Carter denies smoking or drinking, yet social isolation may affect her mental health. She may struggle to adjust to a smaller social circle, therefore proactive steps to encourage social participation should be considered. Encourage seniors to participate in community events, support groups, or senior-specific

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activities to reduce isolation. The broader social backdrop shows that Ms. Carter's social history includes a lifetime of community engagement and relationships. Recognizing and using these social connections can help Ms. Carter manage cognitive decline and improve her health. Review of Systems (ROS): GENERAL: Denies weight loss, fever, chills, weakness, or weariness. This information reveals the patient's general health and eliminates systemic causes of her cognitive disorders. EENT (Eyes, Ears, Nose, Throat):  Eyes: Ms. Carter denies visual loss, blurred vision, double vision, or yellow sclerae. This rules out any acute or chronic ocular issues contributing to her symptoms.  Ears, Nose, Throat: There are no complaints of hearing loss, sneezing, congestion, runny nose, or sore throat. This suggests the absence of any upper respiratory or ear-related infections . SKIN: There is no mention of rash or itching. This information is relevant to rule out dermatological conditions that might be associated with cognitive symptoms . CARDIOVASCULAR: Ms Carter denies chest discomfort, pressure, and agony. She reports no palpitations or edema. These details rule out cardiovascular concerns as an explanation for her cognitive decline. RESPIRATORY: There is no indication of shortness of breath, cough, or sputum. The absence of respiratory symptoms suggests that pulmonary conditions are unlikely to be the primary cause of her cognitive impairment .

GASTROINTESTINAL: Ms. Carter denies anorexia, nausea, vomiting, or diarrhea. Additionally, there is no complaint of abdominal pain or blood. This information rules out gastrointestinal issues as potential contributors to her symptoms . GENITOURINARY: The patient does not report burning on urination. There is no mention of the last menstrual period (LMP), which may not be applicable in this case, as Ms. Carter is postmenopausal . NEUROLOGICAL: Ms. Carter reports difficulty finding words and disorientation to time and place. These neurological symptoms are directly related to her chief complaint and will be further investigated and discussed in the assessment . MUSCULOSKELETAL: There is no mention of muscle pain, back pain, joint pain, or stiffness. Absence of musculoskeletal symptoms helps rule out conditions affecting the motor system as a primary cause of cognitive decline. HEMATOLOGIC: Ms. Carter denies anemia, bleeding, or bruising. This rules out hematologic issues as a significant contributing factor to her symptoms . LYMPHATICS: The patient reports no enlarged nodes, and there is no history of splenectomy. This information suggests the absence of significant lymphatic or immune system issues . PSYCHIATRIC: There is no reported history of depression or anxiety. Although psychiatric factors may contribute to cognitive symptoms, the absence of a psychiatric history does not rule out underlying cognitive disorders . ENDOCRINOLOGIC: Ms. Carter denies reports of sweating, cold or heat intolerance. There is no mention of polyuria or polydipsia, excluding endocrine abnormalities as a primary cause of her cognitive decline.

REPRODUCTIVE : Ms. Carter is not sexually active, and there are no reports of vaginal or penile discharge. Not being pregnant and having no recent pregnancy are relevant for this postmenopausal patient. ALLERGIES: The patient has a history of allergies to penicillin and lisinopril. Although not directly related to her cognitive symptoms, this information is crucial for her overall medical history and any potential future medications . Objective (O): Physical Exam:  Alert and cooperative  Tangential speech  Disoriented to time and place  Eye contact fair  No unusual motor movements or tics Diagnostics/Assessments: 1. CXR: No cardiopulmonary findings. 2. CT head: Diffuse cerebral atrophy. 3. MMSE: Score of 18 out of 30, suggesting moderate dementia. Assessment (A): Primary Diagnosis: Alzheimer's Disease (AD) Following Ms. Carter's comprehensive examination, Alzheimer's Disease is the main diagnosis. Alzheimer's Disease is a neurological disease that causes memory loss, confusion, and cognitive deterioration. Ms. Carter's clinical presentation matches AD's hallmarks: forgetfulness, trouble finding words, and time and place disorientation. The MMSE score of 18 out of 30 supports the diagnosis, indicating moderate cognitive impairment. Her symptoms are most likely caused by

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AD due to the lack of abrupt onset, localized neurological impairments, or cardiovascular risk factors. The CT skull shows diffuse cerebral atrophy, supporting the neurodegenerative character of the illness. Patients and their families face many challenges with Alzheimer's Disease. The plan uses cognitive enhancers like donepezil to manage AD symptoms according to evidence. Further neurologist examination and continuing caregiver assistance are critical to Ms. Carter's comprehensive management strategy. Differential Diagnoses: 1. Vascular Dementia (VaD):  Diagnostic Criteria: Vascular dementia is characterized by cognitive decline resulting from cerebrovascular disease. Risk factors include hypertension, diabetes, and a history of stroke (Uwagbai & Kalish, 2020).  Supportive Documentation: Ms. Carter has a history of hypertension, and the CT head reveals diffuse cerebral atrophy. These findings could be indicative of underlying vascular pathology.  Rule In: Presence of cardiovascular risk factors, cerebral atrophy, and a history of hypertension.  Rule Out: Absence of sudden onset or focal neurological deficits, which are more characteristic of vascular events. 2. Depression with Cognitive Impairment:  Diagnostic Criteria: Depression can present with cognitive impairment, impacting memory and concentration. It's crucial to distinguish depressive cognitive symptoms from primary neurodegenerative disorders (Perini et al., 2019).

 Supportive Documentation: Ms. Carter's daughter reports occasional laughter or dismissal when important details are forgotten, which may be indicative of a mood disorder.  Rule In: Presence of depressed mood, psychomotor retardation, and cognitive symptoms.  Rule Out: Primary neurodegenerative process causing cognitive decline. 3. Normal Pressure Hydrocephalus (NPH):  Diagnostic Criteria: NPH is characterized by ventricular enlargement without increased intracranial pressure, leading to gait disturbances, urinary incontinence, and cognitive decline (M Das & Biagioni, 2020).  Supportive Documentation: The patient denies urinary symptoms, but gait disturbances are not specifically addressed. Evaluation of gait would be important to consider NPH.  Rule In: Presence of gait disturbances, urinary incontinence, and ventricular enlargement on neuroimaging.  Rule Out: Absence of significant urinary symptoms and no mention of enlarged ventricles in the CT head. Plan (P): 1. Diagnostic Studies: Further neuropsychological testing for detailed cognitive assessment. 2. Referrals: Neurologist for a comprehensive evaluation. 3. Therapeutic Interventions: Initiate cognitive enhancers (e.g., donepezil) for presumed AD. 4. Education: Educate caregiver on managing dementia symptoms, provide resources.

5. Disposition: Plan for regular follow-up visits to monitor disease progression. Reflection: This case highlights the difficulty of distinguishing dementia subtypes, which needs a deep study of the patient's clinical presentation and several contributing circumstances. Ms. Carter's memory and executive function deterioration raises questions regarding the cause. Disorientation to time and place may indicate dementia subtypes or associated diseases, complicating diagnosis. Ms. Carter's lack of acute symptoms reflects a neurodegenerative process rather than a vascular incident. This temporal pattern matches Alzheimer's Disease (AD), which causes slow cognitive decline. The gradual nature of AD's memory impairment is a key diagnostic sign. Using cognitive enhancers like donepezil follows evidence-based AD treatment guidelines. In AD patients, cholinesterase inhibitor donepezil improves cognitive function and slows disease development. This drug is based on a thorough understanding of AD's pathogenesis, which emphasizes cholinergic impairments. This approach has drawbacks, which must be acknowledged. Cognitive enhancers can relieve symptoms and stabilize cognitive function, but they cannot cure AD or change its trajectory. The reflection raises questions about psychosocial care, caregiver support, and Ms. Carter's cognitive health. Dementia care is interdisciplinary, emphasizing the need to work with neurologists to refine diagnosis and tailor therapies. The reflection also emphasizes the need for continual review and care plan adaptability, as neurodegenerative illnesses can differ by individual. Health Promotion and Disease Prevention: Encourage caregiver support groups, emphasize importance of mental stimulation activities, and provide resources on community programs for seniors.

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References M Das, J., & Biagioni, M. C. (2020). Normal Pressure Hydrocephalus . PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK542247/ Perini, G., Cotta Ramusino, M., Sinforiani, E., Bernini, S., Petrachi, R., & Costa, A. (2019). Cognitive impairment in depression: recent advances and novel treatments. Neuropsychiatric Disease and Treatment , Volume 15 (15), 1249–1258. https://doi.org/10.2147/ndt.s199746 Uwagbai, O., & Kalish, V. B. (2020). Vascular Dementia . PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430817/

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