Episodic SOAP Note

Episodic SOAP Note

CC: “I keep on forgetting things.”

HPI: FS is a 70-year-old Caucasian female who visits the health center complaining of memory loss that makes him forget things, including the important events. She states that the forgetfulness began about six months back but at a moderate level where it came once in a while. However, the rate has been rising with time progression. The patient is in denial of having sustained head injuries that might have led to the destruction of some neurons in the brain that induces memory encoding, or even after the process, memory stored in the hippocampus are deleted permanently. The rate of his forgetfulness stands at 7/10 on a memory loss scale. The patient, a former senior consultant at one of the organizations in the Telecommunication industry, states that of recent, the issue has been common. She reports that it has led to a loss of important documents, absenteeism from crucial meetings, and lapses in his speech delivery that has made her non-reliable. Irrespective of that, she has been managing her finances alone.

Current medications: The patient has never visited any clinic before for any diagnosis. However, she admits she has taken some OTC drugs such as Aricept 5 mg PO qHD upon a friend’s advice that she may be suffering from Alzheimer’s disease of recent (Karakaya, Fußer & Pantel, 2018). She has been using the pills for about two months. However, such has provided no resolutions as it has only inflated the forgetfulness rate. She asserts that she never uses Benzodiazepines, narcotic painkillers, and cholesterol-lowering medicines, as well as any medication that may interfere with the functioning of the brain.

Allergies: The client admits to having some food allergic reactions but refutes having mood swings leading to some sought of depression. She denies any allergic reactions with regard to drugs and environmental conditions.

PMHx: FS has denied any substantial past medical history, which may have led to her condition. Besides, she was not involved in any accident that may have destroyed some neurons or the hippocampus to causes memory retention problems (Sandeep, Kumar, Mahadevan, & Manoj, 2017). She also denies having undergone any surgical process in his life. She states that he has neither suffered from epilepsy nor motor neuron disease in his life. In fact, the last time he went for some brain check-up, the physicians assured her that everything pertaining to her brain was normal. She has undergone all the vaccinations, even reaching further to getting vaccines boosters for protection against immunizable diseases. She does not remember a time she suffered from any of these ailments.

Soc Hx: FS is a retired employee of one of the leading organizations in the telecommunication industry, where she worked as a senior consultant for eight years. Her experience in the industry though span to over thirty-five years, where she served in various posts. Nowadays, she enjoys going on errands, swimming, and cycling. She is also a fan of football, a game she enjoys watching during her free time. The patient is not married though she has a daughter with whom they live in a rental apartment. The patient neither smoke nor drinks, though she admits she used to drink in her early thirties.

Fam Hx: The client’s family consisted of his mother, father, daughter, and himself. The mother died at the age of 86years of cardiac arrest upon the shock of receiving news that her granddaughter involved in an accident. His father, 94years, suffered diabetes, thyroid conditions, arthritis, and dementia since the loss of his wife and has been in-and-out of the hospital (NHS, 2017). Before the death strike, he remains healthy and very active even in his eighties, with none of the complications. Information about his grandparents remains scanty since they died long before her birth on a plane crash. She is the only child of his parents and remained healthy from any health disorder. Her daughter has completely recovered from the injuries she sustained and has remained healthy henceforth.

ROS

GENERAL: FS refutes having experiencing dizziness, having depression, fatigue, or any other psychological problem or even using the stimulant.

HEAD: The patient had no headache indicating that enough blood flowered to the brain cells without any hindrance.

HEENT: Hearing is equally bilateral with no defect.

CARDIOVASCULAR: The patient denies any heart-related problems such as abnormal blood pressure or pain in the chest.

GASTROINTESTINAL: the patient denied the existence of anorexia, nausea, and vomiting

MUSCULOSKELETAL: denies back pain, and any spinal code injury

PSYCHOLOGICAL: The patient stated he had experienced none of the anxiety, depression, lack of sleep, and delusion.

NEUROLOGICAL: He has not experienced neurotransmitter lapses, which may lead to syncopal episodes or paresthesia. The only issue is a mild cognitive impairment, which manifests in when he failed to remember things.

HEMATOLOGY: the shapes of blood cell are ordinary and make blood movement from and away from the brain sufficient, which ensure enough supply of oxygen. No anemic conditions exist.

LYMPHATICS: No enlargement of nodes.

PSYCHIATRIC: The patient suffers from mild anxiety and depression.

ENDOCTRINAL: Lack of hormonal imbalances. Neither polyuria nor polydipsia exists.

ALLERGIES: hay fever increases the neurogenesis process making one’s brain cells to grow faster. However, AF does not suffer from such allergies.

O.

VS: BP 121/79; HR 72 bpm: RR 26 bpm; temp 97.8; memory loss 7/10. Height 5’9”, weight 179pounds and a BMI of 23.5

Physical exams

GENERAL: AF appearance and medical history show a healthy and well-build individual from the physical assessment. She experiences no fatigue, fever, or change in body weight.

HEAD: the client experiences no headache

CARDIAC: The heartbeat rate is normal without symptoms depicting a problem in the heart or the entire cardiovascular functioning.

RESPIRATORY: the patient denied having track infection, shortness of breath, and even hemoptysis.

GASTROINTESTINAL: no abdominal pain, nausea, vomiting and anorexia.

MUSCULOSKELETAL denies backache, head, and neck muscle pain with free motions of each body part.

PSYCHOLOGICAL: From the physical view, the information the patient provided was satisfactory. He was under mild distress, causing cognitive impairment.

NEURONS: The CN II-VII and DTR were undamaged

HEMATOLOGY: denies having sickle cell anemia, vein thrombosis, and any clotting disorder

Diagnostic results: several blood tests performed gave no clue unto infection or neuron damage. For instance, the TSH, measuring the level of thyroxin for hypothyroidism, was normal. The MRI revealed no damage to the neurotransmitters or any subsequent brain cell tumor. The test also included cerebral angiography that measured blood flow through the brain. The results were normal, indicating that there was no blood deficiency in the brain. The cognitive test indicated that anxiety and distress were the leading causes of such forgetfulness (Mayo Clinic Staff  2019). This emotional disorder disrupts the normal neurotransmitters causing brain lapses hence affecting one’s ability to remember. The poor eating habits accompanied by insufficient bed rest created hormonal imbalance leading to mood swings. Such would later cause brain lapses as a result.

A.

Differential diagnoses

1. Cognitive impairment
2. Dementia
3. Alzheimer disorder
4. Cerebral tumor

With FS age, plus his historical health analysis, the possible disorder causing the disorder is cognitive impairment caused by the psychological distresses and anxiety.  The ability to think and remember things is very important in people’s daily lives. However, cognitive impairment causes mental lapses due to neurotransmitter obstructions making people forget things.

References

Karakaya, T., Fußer, F., & Pantel, J. (2018). Pharmacological Treatment of Mild Cognitive Impairment. 102-108. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3580783/

Mayo Clinic Staff. (2019, April 19). When you should seek help for memory loss. Retrieved from https://www.mayoclinic.org/diseases-conditions/alzheimers-disease/in-depth/memory-loss/art-20046326

NHS. (2017, December 21). Tests for diagnosing dementia. Retrieved from https://www.nhs.uk/conditions/dementia/diagnosis-tests/

Sandeep, C. S., Kumar, S. A., Mahadevan, K., & Manoj, P. (2017). Analysis of MRI and OCT Images for the Early Diagnosis of Alzheimer’s Disease Using Wavelet Networks. AMSE J. Lect. Model. Simul, 31-40. Retrieved from http://amsemodelling.com/publications/lectures_on_modeling_and_simulation/calcutta_04.pdf