Advanced Nurse Practice in Reproductive Health Care
Advanced Nurse Practice in Reproductive Health Care
Episodic/Focused SOAP Note
Patient Information:
E.W., 69, Male.
S.
CC (chief complaint): I cannot hear much of the dialogue on the television
HPI: E.W. is a 69-year-old male patient who presents to the health clinic complaining of difficulty in hearing much of the dialogue on the television. One of the family members who accompany him to the facility complains the patient cannot hear. He continues to work in the school setting. His medical history is quite benign. His only medications are aspirin 81 mg. daily, a multivitamin daily, and occasional ibuprofen for back pain. Speech is clear and coherent but tangential at times. He makes no unusual motor movements and demonstrates no tics. He denies any visual or auditory hallucinations.
Current Medications:
Aspirin 81 mg. daily
Multivitamin daily
Occasional Ibuprofen
Allergies: NKDA
PMHx: Cerumen impactions removed from both ears and back pain. Immunization records are up to date.
Soc & Substance Hx: The patient has no history of substance and alcohol abuse. He is married but not sexually active. He lives with his daughter and his wife. He has worked in the printing company for 35 years. He continues to work in school settings.
Fam Hx: The patient is heterosexual but not sexually active. He is married to one wife and they have a daughter. The wife and the daughter have no significant medical history. The grandparents are deceased for no significant medical history. The couple has no grandchildren.
Surgical Hx: No prior surgical procedures.
Mental Hx: The patient has no significant mental history, dizziness, tinnitus, or vertigo. The patient has no history of depression, anxiety, self-harm, or suicidal ideation.
Violence Hx: He has no history of physical or sexual violence at home, at work, or in the community.
Reproductive Hx: His reproductive system is healthy but he is currently not sexually active. He is a father to one.
ROS:
GENERAL: No unintentional weight loss or gain, fever, and fatigue.
HEENT: Eyes: No blurred vision or yellow sclera. Ears, Nose, Throat: No hearing difficulty, nasal congestion, running nose, or sore throat.
SKIN: No itching, skin rashes, or lesions.
CARDIOVASCULAR: The patient has no chest pressure, edema, discomfort, pain, or palpitations.
RESPIRATORY: No breathing difficulties, sputum, or congestion.
GASTROINTESTINAL: No diarrhea, nausea, eating disorders, blood in the stool.
GENITOURINARY: No problems, pain, or inconsistencies in urination. No history of urinary system illness.
NEUROLOGICAL: No changes in bowel, bladder control, dizziness, or ataxia. The patient has no chronic headache or numbness.
MUSCULOSKELETAL: No pain in the muscles, joints, stiffness, and back.
HEMATOLOGIC: No cases of bleeding or bruising.
LYMPHATICS: The patient has no history of splenectomy. No swollen nodes.
PSYCHIATRIC: The patient has a history of trauma, anxiety, stress, or depression. He was treated for dementia for two years but did not take all the medications or adhere to the counseling guidelines.
ENDOCRINOLOGIC: The patient has no history of polyuria, polydipsia, head, or sweat intolerance.
REPRODUCTIVE: The patient is not sexually active. He has been in a heterosexual marriage. No pain in the reproductive organs, or penile discharge.
ALLERGIES: No known history of drugs, weather changes, asthma, rhinitis, or eczema.
O.
Physical exam:
Vital Signs: 118/80 P: 88 P02: 97% WT: 148 HT: 5’7”
General: A&O * 4, looks sick due to the dull face. The patient is groomed for the clinic visit. He is neat and hygienic and conscious of the surrounding.
HEENT: Eyes: watery eyes. No difficulty in vision. Ears: No hearing difficulty during the conversation, the tympanic membrane is in place. Nose: No itchy or congested nose. Throat: No swollen tonsils.
Neck: JVD, full ROM, carotid no bruit.
Chest/Lungs: CTA AP&L, no dyspnea.
Heart/Peripheral Vascular: The examination shows no murmur or peripheral pulses +2 bilaterally, RRR, or edema.
Abdomen: No abnormal bowel sounds.
Genital/Rectal: Deferred.
Musculoskeletal: No abnormal development or asymmetrical movement. Strength 5/5.
Neurological: DTR intact, CN II – XII intact.
Skin: No skin lesions, rashes, blisters, and plaques.
Diagnostic results:
CXR— no significant cardiopulmonary findings.
MMSE—Ms. Washington scores 18 out of 30 with primary deficits in orientation, registration, attention and calculation, and recall. The score suggests moderate dementia.
A.
Differential Diagnoses
Dementia – dementia is the general term for conditions that lead to loss of memory. The diagnosis of dementia is due to the MMSE score of the patient. The score shows the patient has 18 out of 30. The patient could be experiencing dementia that has various symptoms including limited social skills, forgetfulness, and limited thinking capabilities that interfere with daily activities (Janelidze et al., 2020).
Alzheimer’s disease – Alzheimer’s disease is a progressive disease that leads to memory loss. The condition occurs when the cell connectors die thus undermining the memory capabilities (Bron et al., 2017). The condition can lead to confusion.
PTSD – Post-traumatic stress disorder is a condition that causes traumatic memories and experiences. The condition is common among people who have memories of traumatic events (Bron et al., 2017). The trauma affects the quality of life and participation in daily activities.
P.
The therapeutic interventions for dementia include cholinesterase inhibitors such as Aricept. The purpose of the drug is to improve the chemical involved in the memory and judgment functions in the brain. Aricept 10mg tab bedtime is effective (Nordström & Nordström, 2018). The patient should visit the facility after two weeks for further evaluation. Psychotherapy is another intervention for the treatment of the condition (Nordström & Nordström, 2018). The patient should be referred to a counselor for additional interventions.
The trend of dementia and other mental conditions are common among elderly patients. One of the important lessons is to use both pharmacological and psychotherapeutic interventions to address the symptoms. The best patient education is to encourage adherence to the treatment.
References
Bron, E. E., Smits, M., Papma, J. M., Steketee, R. M., Meijboom, R., De Groot, M., … & Klein, S. (2017). Multiparametric computer-aided differential diagnosis of Alzheimer’s disease and frontotemporal dementia using structural and advanced MRI. European radiology, 27(8), 3372-3382.
Janelidze, S., Mattsson, N., Palmqvist, S., Smith, R., Beach, T. G., Serrano, G. E., … & Blennow, K. (2020). Plasma P-tau181 in Alzheimer’s disease: relationship to other biomarkers, differential diagnosis, neuropathology and longitudinal progression to Alzheimer’s dementia. Nature Medicine, 26(3), 379-386.
Nordström, A., & Nordström, P. (2018). Traumatic brain injury and the risk of dementia diagnosis: A nationwide cohort study. PLoS medicine, 15(1), e1002496.
