571530 EDITED COPY.doc - Running head SOAP NOTE GERIATRIC ASSESSMENT SOAP Note Geriatric Assessment Student Name Course Code Name Institution 1 SOAP

571530 EDITED COPY.doc - Running head SOAP NOTE GERIATRIC...

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Running head: SOAP NOTE: GERIATRIC ASSESSMENT 1 SOAP Note: Geriatric Assessment Student Name Course Code & Name Institution
SOAP NOTE: GERIATRIC ASSESSMENT 2 SOAP Note: Geriatric Assessment Patient Information : An 86 year old African American female. SUBJECTIVE CC: Patient presents to clinic for follow up after 3 weeks on a previously diagnosed pyelonephritis with no complaints saying she feels better now and wants to make sure it stays that way. History of Present Illness : On 8/5/2018, the patient presented with urinary urgency, pain when urinating and urinary frequency. The diagnosis was pyelonephritis and Bactrim was prescribed for her. She has currently visited for a urine recheck and denies experiencing any symptoms associated with the previous diagnosis. Onset : One month ago. Associated Symptoms : frequent, urgent ad painful urination. Current Medication : Bactrim Aricept, Exelon, Razadyne, Namenda started on 8/5/2018 Allergies : No known allergies. Past Medical History : Aricept, Namenda. Prior Illnesses : Alzheimer’s disease, hypertension. Hospitalization : None known. Immunizations : Colonoscopy, pap smears and mammograms. Past Surgical History : None known.
SOAP NOTE: GERIATRIC ASSESSMENT 3 Social History : Widowed two years ago, retired, used to drive a motorcycle, no history of substance abuse, unknown sexual history, no current sexual activity. Family History : Unknown parental history, no siblings, no biological children, two step children. Review of Systems General : Patient seems fine in good health status. HEENT : Atraumatic Eyes: denies any eye problems or visual difficulties Ears: denies ear pain, hearing loss or tinnitus Nose: denies nasal discharge or sinus tenderness. Mouth and Throat: denies any dental issues, denies throat pain. Skin : No skin changes, rashes, hair loss or bruises. Neck : No evidence of swollen glands denies goiter pain, meningitis or lumps. Cardiovascular : Denies chest pain or palpitations. Respiratory : No shortness of breath, wheezing or coughing, denies night sweats. Gastrointestinal : Denies nausea, diarrhea, vomiting or gastrointestinal reflux. Genitourinary : Denies pelvic pain, dysuria, abnormal bleeding, and urinary incontinence. Neurological : Denies extreme headaches, tingling, numbness, dizziness or weakness. Musculoskeletal : Denies joint pain, back pain or neck pain. Hematologic/ Lymphatic : Denies fatigue, denies history of anemia.
SOAP NOTE: GERIATRIC ASSESSMENT 4 Psychiatric : No mood changes, depression, anxiety, insomnia or nervousness.

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