(Student Name)

Miami Regional University

Date of Encounter:

Preceptor/Clinical Site:

Clinical Instructor: Patricio Bidart MSN, APRN, FNP-C

Soap Note # ____ Main Diagnosis ______________

PATIENT INFORMATION

Name: Mr. John Andrews

Age: 76 years

Gender at Birth: Male

Gender Identity: Male

Source: patients daughters.

Allergies: None

Current Medications:

 Lasix 40mg,

 Eliquis 5 mg

 metoprolol 50 mg

 amlodipine 10mg

 simvastatin 40mg

PMH: he was diagnosed with hypertension about 15 years ago. Years six later, he suffered a

cerebrovascular accident. Last year he was diagnosed with heart failure.

Surgical History: none

Family History: both parents died long time age, no known health history. Children are all

healthy. His wife passed away from breast cancer.

Social History: patient lives with a house help in his apartment. He denies smoking, and

drinking alcohol. He occasionally goes forging in the park.

Sexual Orientation:

Nutrition History: takes balanced diet, with low cholesterol, and sodium. Visits a dietician

every four months.

Subjective Data:

Chief Complaint: “We have brought our dad for his annual checkup.”

Symptom analysis/HPI: Mr. John is a 76-year-old male Jewish patient presenting to the clinic

for his annual checkup accompanied by his twin daughters. He states that he is feeling well

generally and is taking medication given during his cardiology visit two weeks ago. However, he

states that he is experiencing memory problems. He explains that he noticed this was not normal

yesterday, when he was not able to differentiate his twin daughters. He cannot clearly remember

when the symptoms began, but he says that they are mild. He denies forgetting procedures like

cooking, coming to the hospital, but admits to frequently misplacing items, which he finds

disappointing.

Review of Systems (ROS)

CONSTITUTIONAL: the patient denies recent effortless weight loss or weight gain. He denies

fever and chills.

extremities. He denies having seizures, headaches currently. He admits having stroke once. He

mentions that he has been experiencing forgetfulness

HEENT: he denies having head surgeries, traumas, or headaches. He denies eye pain, discharge,

or erythema. He denies having blurred vision. He denies changes in hearing, and ringing in his

ears. He denies nose bleeding, nasal discharge, or postnasal drainage. No swallowing difficulties

reported.

RESPIRATORY: patient reports occasional shortness of breath with exertion, or vigorous

activity. He denies difficulty in breathing.

CARDIOVASCULAR: he admits having palpitations occasionally. He denies having recent

chest pains. De denies edema of the extremities.

GASTROINTESTINAL: denies diarrhea, constipation, nausea, or vomiting.

GENITOURINARY: he denies pain or burning sensation during urination. He denies having

diagnosis of prostate gland issues, like hypertrophy and cancer.

MUSCULOSKELETAL: he admits reduced mobility of joints, especially knee joints, although

not stiff.

SKIN: denies rashes, lesions, or tumors. He denies abnormal pigmentation of the skin.

Objective Data:

VITAL SIGNS: blood pressure: 126/83; Pulse: 92; Temp: 98.9F; Weight: 198lbs; Height: 6’5:

BMI: 22.5
GENERAL APPREARANCE: the patient is calm, alert and oriented. He does not appear to be

in acute distress.

NEUROLOGIC: all cranial nerves and reflexes are intact. There is mild deficiency in both long

term and short-term memory.

HEENT: head I free form trauma. He is bald headed, otherwise hair is well distributed in other

areas or the scalp. Eyes are free from erythema, with round, and reactive, no abnormal, or

excessive tearing noted. Eye sight is intact. No drainage moted n the ears. Tympanic membrane

is free from inflammation. There is no septal deviation noted in the nose. Nostrils are pinkish and

free from erythema, or drainage. No sinus inflammation noted either. Oral mucosa is pinkish,

and free from ulcerations. The throat is pinkish too, no evidence of tonsilitis, or pharyngitis.

CARDIOVASCULAR: heart rate and blood pressures are within normal ranges. Pulse’s rhythm

is regular. Capillary refill is 3 seconds, and the patient is free from edema.

RESPIRATORY: breathes are slow, and unlabored.

GASTROINTESTINAL: external genitalia free from ulcerations. Bladder is palpable and non-

distended. There is no evidence of costovertebral angle tenderness. Rectal digital examination of

the prostate reveals normally sized and soft prostate, without ridges.

MUSKULOSKELETAL: both upper and lower limbs have limited range of motion. Joints

affected mostly are the knees and elbow joints.

INTEGUMENTARY: skin is wrinkled, dry, and warm. No ulcerations, or lesions noted. Nails

appear to be thickened, while hair appears to be thin.

ASSESSMENT:
Patient visited the facility for his annual wellness checkup. He is alert and oriented, and has

history of hypertension, heart failure, and stroke. He however mentioned issues with

remembering, especially minor things. He also mentioned reduced flexibility of his joints.

Examination of the patient revealed mild deficits in both of his short-term and long-term

memories. It also revealed limited range of motion in his extremities.

Main Diagnosis

 Alzheimer’s Disease: A clinical condition known as dementia is defined by a steady loss

in at least two cognitive functions, such as memory, language, executive performance,

visuo - spatial activity, character, and behavior (Weller, & Budson, 2018).

Differential diagnosis

 Vascular dementia: occurs following obstruction of blood flow to the brain (Korczyn, et

al., 2012). Considering that the patient suffered once from stroke, this could be a probable

diagnosis, but vascular dementia is characterized with more symptoms like confusion,

and disorientation which are absent in the patient. Therefore, the diagnosis is ruled out.

 Betablocker’s side effects: the patient is taking Beta blockers for his hypertension. One

of the side effects of such medications is that they can lead to memory loss.

 Huntington’s disease: it is a genetically inherited disease that causes degeneration of

nnerve cells. Which can result to memory loss

PLAN:

Labs and Diagnostic Test to be ordered (if applicable)

 - complete blood count: complete blood count is utilized to assess the general health of th

patient. It will be helpful to notice asymptomatic infection, anemia,

Pharmacological treatment:
  None

 Patient should continue with the drugs that he is already taking.

Non-Pharmacologic treatment:

 None.

Education

patient was educated to continue taking the prescribed medications, to alleviate symptoms, as

well as prevent complication. He was also educated concerning his new complains of

forgetfulness, to alleviate the anxiety, and to help him with daily life.

Follow-ups/Referrals: patient was referred to neurologist, for further cognitive assessment to

ascertain root cause of the memory deterioration. He was also referred to a physiotherapist to

help with the reduced flexibility of joints.

Korczyn, A. D., Vakhapova, V., & Grinberg, L. T. (2012). Vascular dementia. Journal of the

neurological sciences, 322(1-2), 2–10. https://doi.org/10.1016/j.jns.2012.03.027

Weller, J., & Budson, A. (2018). Current understanding of Alzheimer's disease diagnosis and

treatment. F1000Research, 7, F1000 Faculty Rev-1161.

https://doi.org/10.12688/f1000research.14506.1