Assignment 2: focused soap note and patient case presentation

Case study

CC (chief complaint)- Almost set the house on fire x2 times

HPI: The patient is Alexis 70 years old woman who is complaining of dementia.

She presents the signs and symptoms of dementia, and she claims having these condition for some time. She states that she has been forgetting things so easily and cannot recall anything Now she is 70 and has begun to have times when she does not know what day it is. Neighbor found her wandering around the neighborhood because she could not find her way home.

Placed items on stove and forgot x2 times and forgot and almost burn the house.The patients states that the condition gets worse when she

vividly recalls her services in the military from training to her retirement. The patient says that there

is no history of dementia in her family and she had the same condition few years

ago. Sister reported the family has concerns of living patient by herself her short-term memory has gotten worse. She was hospitalized for similar symptoms years ago and was placed on Aricept. Patient has mood swings, yell and scream for no reasons, delusional sometimes and behavior problem as reported by her sister, her husband death and son disability has made her condition worse, she has become aggressive and out of control. Tells stories of things that happens in the past over and over again and talks to herself.

The patient was married to her late husband, and they had three children. She has been serving in the

military for over 20 years and has been supporting the community through various activities. She started having a problem with memory loss and difficulty in solving issues. Husband death, daughter had an accident and died, son was shot in his arm and now has disable arm. Sister is her caregiver. Denies seeing things or hearing. Denies suicidal or homicidal ideation.

Medical History: After being taken through various psychiatric test to determine her problems, it

was proven that the patient has dementia.

 Current Medications: Currently, Alexis is under medication where she takes and Aricept 10mg during bedtime for treating

dementia.

 Allergies: She denies having any allergy.

 Reproductive Hx, she is sexually not active

Assignment 2: Focused SOAP Note and Patient Case Presentation

Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Focused SOAP notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.

For this Assignment, you will document information about a patient that you examined during the last 4 weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient.

To Prepare

Select an adult patient that you examined during the last 4 weeks who presented with a disorder other than the disorder present in your Week 3 Case Presentation.

Create a Focused SOAP Note on this patient using the template provided in the Learning Resources.

When you submit your note, you should include the complete focused SOAP note as a Word document and PDF/images of each page that is initialed and signed by your Preceptor.

You must submit your SOAP note using SafeAssign.

Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.

Add five scholarly resources references

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Mental Status Examination:

The patient is who is 70 years old who is forgetting things withing a short time which

seem to be dementia and mood disorder. Since she has been working in the military for over 20 years,

her condition is mainly associated with her worrying experiences and traumatic events in the

warzone. She looks very presentable and smartly dressed thus her general appearance looks good

She is communicating so well with a clear speech, report gets frustrated when she cannot remember things, alert to self and place disoriented to time, confused. She denies hallucination.

despite being previously hospitalized for dementia and depression. However, she gets disrupted at

some point during the conversation. Judgment is impaired, affect labile mood stress and anxious, can not care for self, behavior cooperative and disorganized, thought process tangential, thought content preoccupation, denies SI/HI,