Soap Note

Soap Note

Name:A.K.  Pt. Encounter Number:0004/18
Date:01/03/2018 Age:66Years Sex:Female

In ability to carry out daily activities, refusal to eat, problem in communicating as well as experiencing episodes of confusion and disorientation.


The daughter who was the informant stated that for the last one month, they observed the patient and assisting her in the chores in the house. During the entire period, the patient displayed having short term memory as she could not remember or even keep simple promises. She could also fail to track her purse. Preparing meals is also reported to have been a problem. These problems commences one month ago but has worsened in the last two days when the patient refused to take her meals, had impaired communication as well as having episodes of confusion hence prompted the significant other to bring her to the facility.


Medications: esomeprazole 20mg ones a day and aluminum hydroxide syrup 10mls three times a day for her gastric ulcers that was diagnosed three weeks prior to the day of medical checkup.



Allergies: No known food or drug allergies.


Medication Intolerances:None


Chronic Illnesses/Major traumas: None


Hospitalizations/Surgeries: history of one admission 7 years ago when she had a femur fracture which was treated and was on follow-up until recovery.


Family History

Mother died of heart attack with the father succumbing to injuries in a road accident. Brother; 75 years, Alzheimer’s disease. Husband died of kidney disease secondary to diabetes and hypertension. She has two daughter with no medical history.


Social History

The patient graduated from university and retired as a tutor in a technical institute. She lost her husband 4 years ago. She stays with her daughter in an apartment together with the grandchildren. She does abuse any substance. Both the patient and the significant others uses safety equipment when using cars and playing games. They also observe safety measures at home.



The daughter reported reduces kevel of energy by the patient with no significant change in weight.



No chest pains, edema, chest tightness or palpitations.



Good skin turgor, no bruises, rashes or lesions reported.



No wheezing, shortness of breath or cough, no history of tuberculosis in the patient.



No reports of blurred vision, no use of corrective lenses.



The patient refused to eat in the last two days. No episodes of diarrhea or constipation. No abdominal pains. Positive history of ulcers which is currently being managed.



No pain or discharge reported.



No urinary symptoms, no sexual activities, patient in menopause.




No halitosis or swollen or bleeding gums, no dysphagia or hoarseness of voice, no discharge from the nose.



No muscle pain.

History of fracture femur 7 years ago.



Has knowledge and practices self-breast examination. No lumps.



No history of headaches or seizures.



She is HIV negative as per the previous test in January 2017. No history of blood donation or transfusion, no swollen glands.



Have shown low energy levels with poor communication for the last three days.

Weight: 69 Temp98 BP113/80
Height : 5. 7’’ Pulse77 Resp18
General Appearance

Healthy appearing adult female in low energy. Has communication difficulty as she has problems in finding words. She is alert and well groomed.



Has an intact skin that is clean and warm. No cyanosis in the lips or nails. Good skin turgor.



Head: Normocephalic. Eyes: No discharge, pupils equal and reacts to light. Ears: Patent canals, normal pinna, adequate was bilaterally, gray tympanic membrane. On otoscopy, no discharge from the canals. Nose: Nostrils patent with the septum centrally placed. No nasal flaring. Neck: full range of motion. No lymphadenopathy. All the teeth are present and gum pink. There is no halitosis or bleeding in the gum.



S1 and S2 heard and they are normal. Heart rhythm and rate are regular. Capillary refill of 2 seconds. Pulse rate is 77 beats per minute. No edema on the face and the extremities.



Regular and easy chest rise and fall. Symmetrical chest wall. Resonance sound on percussion. No adventitious sounds heard on auscultation.




No obviousorganomegally, bowel sounds active in all the quadrants


Breast is free from masse or color change. No dimpling or discharge.


Not explored.



Full range of motion for all the extremities. No fractures.



Impaired communication as patient has problem in finding words. She has a stable balance and a normal gait.


Patient shows low energy throughout the assessment period. Impaired speech henceassisted by the daughter in the history taking. Does not maintain eye contact. She is well groomed.


Lab Tests
Magnetic resonance imaging- Pending.

Genetic testing—pending.


Special Tests

Mental Status Examination.

Dementia/Alzheimer Disease.

Common in people of 65 years old and commonly caused by dementia. Risk factors related to the condition include heavy alcohol use, depression, diabetes as well as cardiovascular risks. The patient will present with reduced appetite, confusion and disorientation, inability to engage in daily activities as well as not able to keep appointments(Tom et al., 2015). Impaired speech can also ensue.


Presents with fatigue, psychomotor slowing, sleep as well appetite disturbances, depressed mood and suicidal ideation(Damanti et al., 2016).


It presents with, easy distractions, confusion and impaired thinking but this lasts shortly. It occurs in episodes (Inouye, Westendorp and Saczynski, 2014). The symptoms occurs over hours and fluctuates over the day with some periods occurring without the symptoms.


Final diagnosis

Dementia/Alzheimer – this so because the patient age of 66 shows a predisposition. This is confirmed by the symptoms of memory loss, impaired communication as well as being unable to keep track of belongings. All these are seen in dementia related to Alzheimer. Besides, the symptoms are worsening gradually.



§  Further testing

Genetic testing to determine risky genes (Dubois etal., 2014).

§  Medication

The patient to take memantine 28mg-donepezil 10mg orally once a day in the evening.

§  Education

The significant other to be taught on assistive services to the patient as well as close monitoring to prevent harmful behaviors. This also extends to drug adherence and compliance.

§  Nonmedication treatments

The patient need to engage in exercise activities as well as social interaction which will assist in reducing the current symptoms.Maintaining a balanced diet is essential in providing vitamin D and omega 3 fatty acids that reduces the symptoms of dementia.

§  Follow-up

The patient will be on follow up and come for the clinics monthly to monitor the progress. She however can come back in case the situation worsens.



Damanti, S., Romano, F. Y., Abbate, C., Schinco, G. L., Rossi, P. D., Mari, D., & Marcucci, M. (2016). Depression or prodromal fronto-temporal dementia?. Official Journal of the Italian Society of Gerontology and Geriatrics, 25.

Dubois, B., Feldman, H. H., Jacova, C., Hampel, H., Molinuevo, J. L., Blennow, K., … & Cappa, S. (2014). Advancing research diagnostic criteria for Alzheimer’s disease: the IWG-2 criteria. The Lancet Neurology13(6), 614-629.

Inouye, S. K., Westendorp, R. G., & Saczynski, J. S. (2014). Delirium in elderly people. The Lancet383(9920), 911-922.

Tom, S. E., Hubbard, R. A., Crane, P. K., Haneuse, S. J., Bowen, J., McCormick, W. C., … & Larson, E. B. (2015). Characterization of dementia and Alzheimer’s disease in an older population: updated incidence and life expectancy with and without dementia. American journal of public health105(2), 408-413.