Mild cognitive impairment SOAP Note
To Prepare
By Day 1 of this week, you will be assigned to a specific case study for this Case Study Assignment. Please see the “Course Announcements†section of the classroom for your assignment from your Instructor.
Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.
With regard to the case study you were assigned:
Review this week\’s Learning Resources, and consider the insights they provide about the case study.
Consider what history would be necessary to collect from the patient in the case study you were assigned.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient\’s condition. How would the results be used to make a diagnosis?
Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
The Case Study Assignment
Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient\’s differential diagnosis, and justify why you selected each.
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Case study:
A 70-year-old female comes to your clinic with complaints of forgetfulness. She noticed it about a year ago and it has progressively gotten worse. She sometimes forgets what she is going to do when she gets to another room. Her family has noticed the problem with her forgetfulness but she is still able to manage her finances and drive, per her report.
Solution
SOAP Note
Student’s Name
Institutional Affiliations
SOAP Note
Patient Information:
Initials: R. C. Age: 70 years old Sex: Female Race: White
S.
CC: “I am forgetful. I often forget what I have planned to do.”
HPI: R. C. is a female patient currently aged 70 years. She has reported to the clinic complaining of forgetfulness. The problem began about a year ago and it has worsened with time. The patient’s forgetfulness has become severe such that she cannot remember what she had planned to do when she gets to another room. However, she is still in a position to drive and manage her finances.
Current Medications: None
Allergies: No known allergies reported
PMHx: R. C. has never been diagnosed with a serious medical condition before. She was once treated for malaria symptoms in her 30s but she was not hospitalized. She cannot remember any other illness she has been treated for in the past.
Soc Hx: R. C. is a retired teacher. She retired from teaching at the age of 60. R. C. is married with children. Her husband is currently 78 years old and her children no longer stay at home. She rarely engages in physical exercise. However, she is able to perform activities of daily living without assistance.
Fam Hx: None of her family members has been diagnosed with a serious disease. Her husband is experiencing physical mobility challenges due to old age.
ROS:
GENERAL: R. C. denies a significant weight loss and fever.
HEENT: Head: Denies head injury. Eyes: Denies vision loss. Ears: Denies hearing difficulties. Nose: Denies runny nose or nasal congestion. Throat: Denies a sore throat
CARDIOVASCULAR: Denies chest discomfort or chest pain.
RESPIRATORY: Denies shortness of breath, cough, breathing difficulties.
NEUROLOGICAL: No headaches. Denies numbness on the limbs. However, R. C. has complained of forgetfulness.
HEMATOLOGIC: No hemophilia, no blood disorders
PSYCHIATRIC: Denies psychiatric issues such as anxiety and depression.
ENDOCRINOLOGIC: Denies abnormal night sweats.
ALLERGIES: R. C. denies allergies to either food or drugs.
O.
Vital signs: Temperature: 36.3 degrees Celsius, Respiratory rate: 19, Blood pressure: 102/75, BMI: 22 kg/m2.
General: R. C. is seated upright. She appears disturbed with her condition. The patient is attentive and keeps eye contact.
HEENT: Head: No signs of trauma or injury Eyes: The conjunctiva is clear, no signs of redness Ears: The pinnas are externally positions, no discharge, ears are sensitive to sound. Nose: No drainage, nasal mucosa is pink and hairy Throat: No lesions, no erythema.
Neck: No tenderness, trachea is positioned at the midline.
Skin: The skin is warm and smooth, with no rashes.
Neurological: R. C. forgets things within a very short period of time. She can hardly recall what has been planned recently.
Diagnostic results: Conduct a complete neurological examination, conduct a mini-mental status examination to evaluate the patient’s cognition, memory, and attention.
A.
Differential Diagnoses
- Mild cognitive impairment
- Depression
- Delirium
- Dementia
- Normal age-associated bodily changes
Primary diagnosis: Mild cognitive impairment
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
Emmady, P. D., Tadi P. (2020). Dementia. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK557444/
Prakash, O., & Jha, S. (2016). Differential diagnosis for cognitive decline in elderly. Journal of Geriatric Mental Health, 3, 21-8. https://www.jgmh.org/text.asp?2016/3/1/21/181911
Yoon, P. S., Ooi, C. H., & How, C. H. (2018). Approach to the forgetful patient. Singapore Medical Journal, 59(3), 121–125. https://doi.org/10.11622/smedj.2018026