SOAP Note Template
Encounter date: _3/4/20_______________________
Patient Initials: _MN_____ Gender: M/F/Transgender _M___ Age: _81____ Race: _Black____ Ethnicity African____
Reason for Seeking Health Care: _Patient has been having issues with low cognition and the presence of retrograde amnesia and disorientation for three months._____________________________________________
HPI: Patient was well until three months ago when he presented with a history of confusion and disorientation. There’s also the presence of retrogade amnesia, according to the informants. There was no prior history of trauma, according to the informants. It is the first episode of such nature._______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Allergies(Drug/Food/Latex/Environmental/Herbal): ____Patient has no known allergies._______________________________
Current perception of Health: Excellent Good Fair Poor
Past Medical History
Major/Chronic Illnesses There’s no history of chronic illnesses in the patient.__________________________________________________
Trauma/Injury _No prior history of trauma/injury.__________________________________________________________
Hospitalizations _No prior history of hospitalizations._________________________________________________________
Past Surgical History The patient has never had any surgical interventions._________________________________________________________
Medications: _Patient does not take any long-term medications._________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Family History: __There’s a maternal familial history of hypertension.__________________________________________________________
Social history:
Lives: Single family House/Condo/ with stairs: __Condo with stairs_________ Marital Status:_Married_______ Employment Status: Retired______ Current/Previous occupation type: _________________
Exposure to: ___Smoke_N/A___ ETOH N/A____Recreational Drug Use: ___N/A_______________
Sexual orientation: _Straight______ Sexual Activity: N/A____ Contraception Use: ____________
Family Composition: Family/Mother/Father/Alone: __Lives with extended family.___________________________
Health Maintenance
Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _N/A____
Exposures: N/A
Immunization HX: Up to date
Review of Systems:
General: Patient has a history of confusion and disorientation.
HEENT: This system is non-remarkable.
Neck: This system is non-remarkable.
Lungs: This system is non-remarkable.
Cardiovascular: This system is non-remarkable.
Breast: This system is non-remarkable.
GI: This system is non-remarkable.
Male/female genital: This system is non-remarkable.
GU: This system is non-remarkable.
Neuro: This system is non-remarkable.
Musculoskeletal: This system is non-remarkable.
Activity & Exercise: This system is non-remarkable.
Psychosocial: This system is non-remarkable.
Derm: This system is non-remarkable.
Nutrition: There a history of anorexia, according to the patient.
Sleep/Rest: The patient presents with episodes of insomnia
LMP: This system is non-remarkable.
STI Hx: This system is non-remarkable.
Physical Exam
BP_125/77_______TPR_37.3____ HR: _80____ RR: 25____Ht. _174____ Wt. _70_____ BMI (percentile) _23____
General: Patient is in a good nutritional status with no pain and respiratory distress.
HEENT: This system elicits no signs of physical abnormalities.
Neck: This system is non-remarkable.
Pulmonary: This system is non-remarkable.
Cardiovascular: This system is non-remarkable.
Breast: This system is non-remarkable.
GI: This system is non-remarkable.
Male/female genital: This system is non-remarkable.
GU: This system is non-remarkable.
Neuro: Reflexes are intact, power of all the synonymous muscle groups is 5. It is worth noting that all the muscles have adequate bulk and power on the contralateral sides.
Musculoskeletal: This system is non-remarkable.
Derm: This system is non-remarkable.
Psychosocial: This system is non-remarkable.
Misc. Cranial nerves are intact.
Plan:
Differential Diagnoses
1. Senile Dementia
2. CVA (Cerebrovascular Accident)
3. Delirium
Principal Diagnoses
1. Senile Dementia
2. CVA (Cerebrovascular Accident)
Plan
Diagnosis Senile Dementia
Diagnostic Testing: Evaluation includes the exclusion of other diseases and trying to identify the cause of the dementia. A Head CT scan, critically, results in the identification of atrophied gyri. The baseline tests are fundamental in the ruling out of other diseases.
Pharmacological Treatment: Ceregard tab OD.
Education: Informants may need to understand the causes of dementia and the need to have home-based care to ensure no extra comorbidities.
Referrals: There would be need for referral.
Follow-up: Regular follow-up by a geriatrist is critical.
Anticipatory Guidance: The patient may require other supportive management such as physiotherapy.
Diagnosis CVA
Diagnostic Testing: A head CT Scan and MRI would help in the identification of the space occupying lesions (SOL).
Pharmacological Treatment: In case of hemorrhagic CVA; the anti-hypertensives would be essential in the lowering of BP levels. Statins and Aspirin would be effective in the management of Ischemic CVA.
Education: There would be need for lifestyle modification through incorporation of exercise and low-fat diet.
Referrals: There would be need for referral to a neurosurgeon in case of extensive hemorrhage.
Follow-up: Follow-up in a medical outpatient clinic (MOPC) would be crucial.
Anticipatory Guidance: It would be helpful to assess the BPs regularly to avoid a repeat of the medical issue.
Signature (with appropriate credentials): __________________________________________
Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________
DEA#: 101010101 STU Clinic LIC# 10000000
Tel: (000) 555-1234 FAX: (000) 555-12222
Patient Name: (Initials)______________________________ Age ___________
Date: _______________
RX ______________________________________
SIG:
Dispense: ___________ Refill: _________________