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

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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 hasa 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.

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Written in
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