ALZHEIMER’S DISEASE SOAP NOTE 2
PATIENT INFORMATION
NAME: C. M
AGE: 70 years
SEX: Female
SOURCE: Patient
ALLERGIES: NKDA
CURRENT MEDICATIONS: None
PMHX: Patient confirms history of Down syndrome; patient confirms
...
ALZHEIMER’S DISEASE SOAP NOTE 2
PATIENT INFORMATION
NAME: C. M
AGE: 70 years
SEX: Female
SOURCE: Patient
ALLERGIES: NKDA
CURRENT MEDICATIONS: None
PMHX: Patient confirms history of Down syndrome; patient confirms history of osteoporosis;
confirms past hospitalization because of an accident; confirms past head trauma as a result of the
accident; denies blood transfusion hx
FAMHX: Father had a history of hypertension; mother’s hx is positive for Alzheimer’s disease;
patient has two children in good health
SOHX: Patient denies alcohol consumption of use of recreational drugs; patient stays at home
with husband; grandchildren come to visit occasionally
IMMUNIZATIONS: All immunizations up-to-date
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https://www.coursehero.com/file/61920971/Alzheimerdocx/
ALZHEIMER’S DISEASE SOAP NOTE 3
SUBJECTIVE:
CC: Patient comes to the clinic and verbalizes, “I have a problem with my memory. I seem to
forget recent events and I have difficulty organizing my thoughts”.
S: HPI: A 70-year-old man visits the clinic with complaints of problems with memory. She
seems to forget recent events in her life and has great difficulty organizing her thoughts. AAlso,
patient states that she repeats statements and questions over and over even after making the
statements before. He has also been forgetting conversations and appointments. She often
misplaces her possessions and has gotten lost two times in the neighborhood. She also reports
difficulty concentrating and thinking. Patient also finds it difficult to multi-task and she finds it
extremely difficult to respond to the daily problems. She has also been experiencing changes in
personality and behavior including aspects such as depression, social withdrawal, mood swings,
apathy, changes in sleeping habits, and delusions. She denies fever, vomiting, constipation, and
diarrhea.
ROS:
CONSTITUTIONAL: Patient seems to be far in though. She seems to lose track of our
discussion and does not seem to concentrate. She forgets so fast and looks withdrawn
Head: Confirms hx head trauma
Skin: Patient denies skin rashes; denies dry or scaly skin
Eyes: Confirms change in vision; confirms use of corrective lenses to focus
Ears: Denies drainage
Nose: Denies congestion; denies stuffy nose
This study source was downloaded by 100000832361371 from CourseHero.com on 08-14-2022 23:13:46 GMT -05:00
https://www.coursehero.com/file/61920971/Alzheimerdocx/
ALZHEIMER’S DISEASE SOAP NOTE 4
Mouth/Throat: Denies sores in the mouth or tongue; denies dental bleeding or pain; denies sore
throat
Neck: Denies pain in the neck
Cardiovascular: Denies missing beats or irregular pulse
Respiratory: Denies pain on inspiration and expiration
Gastrointestinal: Patient denies nausea, vomiting
Musculoskeletal: Denies joint or muscle pain; denies stiffness
OBJECTIVE:
CONSTITUTIONAL: Temperature 97.6; Pulse 68; Respirations 18; BP 145/65; Height 6’ 14’’;
BMI 25.62; Weight 140 lbs
Lungs: No rales or rhonchi
Cardiovascular: S1 and S2 normal; extremities are dry
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