SOAP NOTE for Follow Up Visit

Patient: R.K.

Visit Date: 8/31/2022

Chief Complaint (CC): Voices no concerns at this time

Subjective (S): Remember to use the “Old Cart”

History of Present Illness: R.K. is a 77-year-old male who resides at the Inn at Poland Way, with a
Palliative diagnosis of Alzheimer’s disease. PMH: Alzheimer’s disease, HTN, HLD, prostate CA. Patient
seen and examined, discusses with nursing. Nursing voices concerns of quick regression. Nursing states
patient had a fall about 2 weeks ago, and since he has declined. Patient has become increasingly
agitated, confused, refusing care and interaction. Increased episodes of Incontinence has become an
issue with patient as well. Nursing also notes patient requires medications to be crushed which is new.
During exam, patient was found to be sitting in recliner chair asleep. Patient was easily aroused, but did
not want to do an exam. Patient stating, "he does not want any doctors". Patient was A&Ox1 to person
only. Patient was uncooperative, but denied any concerns. Patient stated he was not in any pain at this
time. Patient refused vitals, asked nursing staff to attempt, patient became combative during attempt,
only some vitals were obtained. Discussed findings with wife. Code Status: DNRCC

Medical/Surgical History: Alzheimer’s disease, HTN, HLD, Prostate CA

Social/ Personal History: Retired. Married for 52 years with 3 children near-by. Resides at the Inn at
Poland way.

Sexual History: Married x52 years

Medications: Aricept, Nmenda, Metoprolol, Lisinopril, Casodex, Tamoxifen, Seroquel, Lipitor

Immunizations: Up to date, Received 3 Covid shots, and annual flu vaccine

Family History: Mother: deceased HTN, Dementia. Father: Deceased, prostate CA, Dementia. Son 1: No
known medical HX. Son 2: HTN. Daughter 1: no known medical HX.

Review of Systems

General:

Neurologic: denies fatigue, weakness, or weight loss/gain

Psychologic: denies thoughts of suicide or depression, anxiety

Head/Neck: denies neck pain or swollen lymph nodes

EENT: Denies blurred vision or visual complaints, denies nasal congestion, rhinitis, frequent URI,
hearing issues or tinnitus
Respiratory: denies cough, wheezing, or shortness of breath

Cardiovascular: denies chest pain, palpitations, edema

Abdominal: reports daily bowel movements, denies constipation, bloating, diarrhea, or

abdominal pain
Genitourinary: reports incontinence, denies issues voiding, trouble initiating stream, denies pain or
dysuria

Integumentary: denies rash, nevi, lesions

Musculoskeletal: denies weakness, muscle pain, stiffness, cramping

Objective (O): Physical findings and lab and diagnostic results

Height/Weight: 5’8” / 176 lbs.

BMI: 26.8

MAC: 26.1

Vital Signs:

Physical Exam
General Survey: well-nourished, clean, uncooperative, appropriate for developmental age
Neurological: Alert, oriented to person, uncooperative, CN I-XII Intact.
Head/Neck: normocephalic, atraumatic, no lymphadenopathy noted.
EENT: PERRLA, fundoscopic exam grossly normal, mucus membranes pink moist and intact, no
nasal discharge noted, uvula midline, tonsils 1+ without redness or exudate, bilateral TM pearly
gray.
Respiratory: regular rate and depth, diminished to auscultation bilaterally, capillary refill <3
seconds
Cardiovascular: regular rate and rhythm without murmur or click, peripheral pulses palpable
3+bilaterally without edema.
Abdominal: BS active x4 quadrants, soft, non-tender, no palpable masses or pulsations noted
Integumentary: no rashes, lesions or nevi noted
Musculoskeletal: full rom all extremities without weakness 4/5 strength upper and lower
extremities bilaterally

Labs and Diagnostics:

Assessment (A): Problems and Primary Diagnosis

Primary Diagnosis: Worsening Alzheimer’s

Differential Diagnosis:

Worsening Alzheimer’s Disease

UTI

CVA

Electrolyte Imbalance

Problems:

Alzheimer's disease G30.9

Increased Behaviors F01.51

Prostate cancer C61

HTN I10

HLD E78.5

Plan (P): Includes medications, labs, diagnostic tests, referrals

Alzheimer's Disease - Monitor behaviors ; Fall precautions per facility policy ; Cont. Namenda and
Aricept.

Increased Behaviors - Obtain UA & C&S, Obtain CMP, & CBC with Diff., obtain CT head and neck, Start
Ativan 0.5 mg PO BID for increased agitation. Continue Seroquel 100 mg PO QHS

Prostate cancer – Cont. Casodex and Tamoxifen

HTN - BPs reviewed ; Cont. metoprolol and lisinopril ; Hold beta blockers for SBP < 100 and/ or HR < 60 ;
Hold Ca+ channel blocker for SBP < 100

HLD – Cont. Lipitor

Lab/Diagnostic: Obtain UA & C&S, obtain CMP, CBC w/ Diff., CT Head and neck

Follow up visit:

Results of Urine and CBC/CMP called and reported to me. Follow up in 1 week to evaluate behaviors, lab
results, CT scan results, and medication changes.

Signature:_________Hannah Gallagher_______________ Date:_________09/06/2022____________