Case 2: Forgetfulness (Last Name N-Z) Asia brings her 67-year-old father into the office stating he is very forgetful. He has lost his car keys sev
Case 2: Forgetfulness (Last Name N-Z)
Asia brings her 67-year-old father into the office stating he is very forgetful. He has lost his car keys several times. She also states he has driven to the store and called her asking for directions to get back home
Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient's differential diagnosis and justify why you selected each.
Week 9
Shadow Health Comprehensive SOAP Note Template
Patient Initials: _______ Age: _______ Gender: _______
SUBJECTIVE DATA:
Chief Complaint (CC):
History of Present Illness (HPI):
Medications:
Allergies:
Past Medical History (PMH):
Past Surgical History (PSH):
Sexual/Reproductive History:
Personal/Social History:
Health Maintenance:
Immunization History:
Significant Family History:
Review of Systems:
General:
HEENT:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Neurological:
Psychiatric:
Skin/hair/nails:
OBJECTIVE DATA:
Physical Exam:
Vital signs:
General:
HEENT:
Neck:
Chest/Lungs:.
Heart/Peripheral Vascular:
Abdomen:
Genital/Rectal:
Musculoskeletal:
Neurological:
Skin:
Diagnostic results:
ASSESSMENT:
PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.
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