Soap note | NURS 6540 – Advanced Practice Care of Frail Elders | Walden University

Week 2 Case 2: Alzheimer’s

Ms. Washington is a 67-year-old African American female who is brought to your office by her daughter with concerns of “forgetfulness.” She has lived with her daughter for 4 years now, and her daughter reports noticing she asks the same questions even after they have been answered. She even reports her mom getting lost in Walmart recently. Ms. Washington has lived with her daughter since losing her husband of 57 years, about 4 years ago. Her daughter states her mother is a retired teacher and usually very astute but notices more forgetfulness. 

According to Ms. Washington’s daughter, Angela, her mom has been demonstrating increased forgetfulness of more recent things but can easily recall historical moments and events. She also reports that sometimes her mom has difficulty “finding the right words” in a conversation, and then will shift to an entirely different line of conversation. She also said her mother will “laugh off” things when she forgets important appointments and/or become upset or critical of others who try to point these things out. 

Note: Be sure to review the Mini-Mental State Exam (MMSE) and how to interpret results. Use the MMSE, in the attached document, to determine the patient’s MMSE score in the video. Make sure you document the patient’s score in your SOAP note document: Mental State Assessment Tests.

Ms. Washington is a 67-year-old female who is alert, cooperative with today’s clinical interview. Her eye contact is fair. Speech is clear and coherent but tangential at times. She makes no unusual motor movements and demonstrates no tics. She denies any visual or auditory hallucinations. She denies any suicidal thoughts or ideations. She is alert and oriented to person, partially oriented to place but is disoriented to time and place. (She reported that she thought was headed to work but “wound up here,” referring to your office, at which point she begins to laugh it off.) She denies any falls or pain. 

All other Review of System and Physical Exam findings are negative other than stated.

PMH: Hypertension, Hyperlipidemia, Osteoporosis 

Allergies: Penicillin, Lisinopril

Medications:

  • Amlodipine 10mg daily
  • HCTZ 12.5mg daily
  • Multivitamin daily
  • Atorvastatin 40mg daily
  • Alendronate 70mg orally once a week

Social History: As stated in Case Study

ROS: As stated in Case study

Diagnostics/Assessments done: 

  1. CXR—no cardiopulmonary findings. WNL
  2. CT head—diffuse Cerebral Atrophy
  3. MMSE—Ms. Washington scores 18 out of 30 with primary deficits in orientation, registration, attention and calculation, and recall. The score suggests moderate dementia. 

The Assignment:

Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:

  • Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the American Geriatrics Society Beers Criteria®, and consider alternative drugs if appropriate. Provide a review of systems.
  • Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results? How would you interpret and address the results of the Mini-Mental State Examination (MMSE)?
  • Assessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. Compare the diagnostic criteria for each, and explain what rules each differential in or out. Explain you critical thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
  • Plan: Provide a detailed treatment plan for the patient that addresses each diagnosis, as applicable. Include documentation of diagnostic studies that will be obtained, referrals to other healthcare providers, therapeutic interventions, education, disposition of the patient, caregiver support, and any planned follow-up visits. Provide a discussion of health promotion and disease prevention for the patient, taking into consideration patient factors, past medical history (PMH), and other risk factors. Finally, include a reflection statement on the case that describes insights or lessons learned.
  • Provide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care. Follow APA 7th edition formatting. 
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