SOAP NOTE: GERIATRIC ASSESSMENT2SOAP Note: Geriatric AssessmentPatient Information: An 86 year old African American female.SUBJECTIVECC: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 8/5/2018Allergies: 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 ASSESSMENT3Social 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 SystemsGeneral: 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 ASSESSMENT4Psychiatric: No mood changes, depression, anxiety, insomnia or nervousness.