Episodic/Focused SOAP Note
Patient Information:
Initials: S.T. Age: 70 years Sex: Female Race: Hispanic
S
CC (chief complaint): “I have forgetfulness.”
HPI: S.T. is a 70-year-old Hispanic female who has visited the clinic accompanied by her daughter. Her chief complaint is forgetfulness. She reports that her symptoms began a year ago, but they have gotten worse over the years. S.T. further indicates that she sometimes forgets what she is going to do when she gets to another room. According to her daughter, the family has noticed the problem with their mother’s forgetfulness. However, she is still able to manage her finances and drive.
Location: Psychological
Onset: 1 year ago
Character: Abstract
Associated signs and symptoms: Not indicated
Timing: Anytime
Exacerbating/ relieving factors: None mentioned
Severity: Mild
Current Medications: None
Allergies: No known drug or food allergies reported.
PMHx: S.T. is unable to remember childhood immunization history. She received Johnson & Johnson COVID-19 vaccine on 12/06/2021. She received her last tetanus vaccine 8 years ago in April 2014, but she cannot recall the date. S.T. reports a history of hospitalization which happen in her late 40s due to pneumonia complications.
Soc Hx: S.T. is a retired high school teacher. Her husband is an engineer. She denies cigarette or alcohol consumption. She hardly engages in exercise. S.T. spends a part of the day on the farm. She uses her car in case she wants to go to town. She eats a lot of fruits and vegetables and hardly eats red meat. Family members have reported a problem with her forgetfulness.
Fam Hx: S.T. reports that her father and mother died several years ago from stroke and a cardiovascular complication respectively. She denies the presence of a chronic condition among the living members of her family.
ROS:
GENERAL: Denies fever, abnormal changes in weight, reports forgetfulness.
HEENT: Does not report a recent head injury, visual loss, ear pain, nasal congestion, or sore throat.
SKIN: Does not report itchiness or rashes.
CARDIOVASCULAR: No chest discomfort or pain reported.
RESPIRATORY: No shortness of breath or cough reported.
GASTROINTESTINAL: Denies abdominal pain or discomfort.
GENITOURINARY: Denies a burning sensation in the genitalia during urination.
NEUROLOGICAL: Reports forgetfulness or memory loss. Denies tingling or numbness of the extremities.
MUSCULOSKELETAL: Denies joint-related pain or a problem with gait.
HEMATOLOGIC: Denies a history of blood disorders.
LYMPHATICS: Does not report pain or swelling of the lymphatics.
PSYCHIATRIC: No anxiety reported. Denies stress. Reports forgetfulness or memory loss.
ENDOCRINOLOGIC: Denies abnormal sweats at night.
ALLERGIES: No drug or food allergies reported.
O.
Vital signs: Temperature: 98 degrees Fahrenheit, blood pressure: 121/80, respiratory rate: 18 breaths per minute, heart rate: 92 beats per minute, weight: 152.7 lb, height: 5.8 feet, BMI: 23.2 kg/m2.
General appearance: S.T. is also properly oriented to person, place, and time.
Skin: Warm, hairy, and n
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