NRNP 6540 Week 2 SOAP Note | Advance Practice Care of Frail Elders

NRNP 6540 Week 2 SOAP Note | Advance Practice Care of Frail Elders. History of Present Illness (HPI): BW is a 67 YO, female, AA who is brought in today by her daughter with increased forgetfulness, confusion, lack of short-term memory and inappropriate laughing which has gotten progressively worse recently. She has a history of hypertension, hyperlipidemia, and osteoporosis which are controlled with medication. She denies any vision changes, dizziness, headaches, or vertigo. She reports osteoporosis but denies pain able to ambulate without assistance or medical devices. She denies any pain traveling down her legs. She does report that her pain is increased with activity. She reports her pain as 2/10 on the numeric pain scale. She denies any fever, chills, nausea, vomiting, pain with urination, hematuria, foul smelling urine, urinary frequency or urgency. BW is alert, cooperative with today’s clinical interview. Her eye contact is fair. Speech is clear and coherent but tangential at times. She makes no unusual motor movements and demonstrates no tics. She denies any visual or auditory hallucinations. She denies any suicidal thoughts or ideations. She is alert and oriented to person, partially oriented to place but is disoriented to time and place. (She reported that she thought was headed to work but “wound up here,” referring to your office, at which point she begins to laugh it off.) She denies any falls or pain. Daughter states symptoms have become more frequent and more prevalent. Medications:  Amlodipine 10mg PO daily: since 2010, for HTN  HCTZ 12.5mg PO daily: since 2010, for HTN  Multivitamin tabs one PO daily: since 2000  Atorvastatin 40mg PO qhs: since 2010, for hyperlipidemia  Alendronate 70mg PO once a week: since 2018, for post-menopausal osteoporosis Allergies:  Penicillin: hives;  Lisinopril: cough, headache, dizziness.  No food, environmental, or seasonal allergies. Past Medical History (PMH): Daughter states all immunizations are current. Had first pneumonia vaccine in 2018 when she turned 65 YO, annual influenza in October and Tdap booster. Denies past major illnesses or surgeries. Social and Substance Hx: BW is a retired teacher who retired at age 65. She enjoys yard work, is active in her church and occasionally volunteers in the local food bank. Denies ever smoking or alcohol use. Denies any illicit drug use. Has lived with her daughter for the last four years since her husband passed away. Daughter states she has no weapons in the home, has a working smoke alarm on each floor of her home, and affirms her mother always wears her seatbelt in the care. However, hasn’t been driving for the past year due to concerns with her memory lapses. Doesn’t have a cell phone but occasionally uses her laptop. Family Hx: Denies any illnesses with possible genetic predisposition, contagious, or chronic illnesses. O family history of Sickle Cell crisis or traits. No siblings. Parents have been deceased since childhood from MVA. Maternal and paternal grandparents are all deceased, from unknown reasons. Has one daughter, alive and well and one granddaughter alive and well. Surgical Hx: No prior surgical procedures. Mental Hx: