Episodic SOAP for dementia. Patient Information:
76-year-old Male, Caucasian.
S.
CC: ‘I keep forgetting things and it is worrying me.” The patient was brought in by his son who
said that the father has had episodes of forgetfulness. The patient said that he noticed his short
memory losses ...
CC: ‘I keep forgetting things and it is worrying me.” The patient was brought in by his son who
said that the father has had episodes of forgetfulness. The patient said that he noticed his short
memory losses eight months ago and has become progressively worse. He also said that
sometimes he gets into a room and immediately forgets whey he went to the room. He however
states that he is able to drive and carry out his ADLs with no assistance.
HPI: Location: forgetfulness
Onset: the last eight months
Character: Patient appeared pleasant though he seemed nervous and worried. He
appeared to know why he had come to the clinic though at one point he asked the same
question twice (who are you and why am I here?).
Associated signs and symptoms: patient did not have direct eye when answering
questions. Patient reported feeling sadness over the loss of his wife eleven months ago.
He has been diagnosed with mild anxiety
Timing: The patient does not recall when he looses his memory except for the mention
that at times he walks into a room and does not remember why he went to the room.
Exacerbating/ relieving factors: Following the death of his wife, the patient has had more
frequent memory losses. He visits his wife’s grave and lays some flowers to help him
forget his loneliness. He said that this action also helps him remember the haapy times he
and his wife of 48 years shared.
, Current Medications: Lisinopril for HTN 20mg/day. Amlodipine 5 mg. Vitamin supplements
Allergies: NKDA
PMHx: COVID-19 vaccination in May 2021. Flu shot in March of 2020. Tetanus booster shot in
August of 2020.
Soc Hx: The patient is a widower with two sons and three daughters. He has 7 grandchildren.
He lives by himself in a house that he and his wife bought 24 years ago. The house is certified to
meeting HVAC standards for air conditioning and heat system. The house is well ventilated and
has a bunker in case of a hurricane. The patient is a retired firefighter. He likes to spend his time
at his Deli which he owns but no longer runs following his wife’s demise. He also likes to play
golf on the weekends. The patient does not smoke or take alcoholic beverages. The patient uses a
safety belt while driving. The patient takes evening walks with his dog and that makes up for his
exercise routine on a daily basis.
Fam Hx: Patient’s father is deceased, HTN. Mother is deceased, diabetes. The patient’s sister
has CHF and is diagnosed with mild depression.
ROS:
GENERAL: Weakness and fatigue. He reports a lack of appetite and has lost 13 pounds in 8
months. Patient has trouble sleeping.
HEENT: Head: No lesions. The head is atraumatic and normocephalic. Eyes: Patient uses
contact lenses. Denies ocular pain or blurred vision. Ears: No discharge, ringing, pain or hearing
loss. Nose: Inner nasal membrane was pink and moist. No sinus or nose bleeds. Throat: No sore
throat or hoarseness
SKIN: Denies itching or rashes
CARDIOVASCULAR: Denies chest pains or chest discomfort. No edema or palpitations
RESPIRATORY: Denies sputum or cough, or shortness of breath.
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