Wk2 SoapNote BoggsJ

Patient Information: Mrs. P., 70 y.o., Caucasian, Female S (subjective) CC: Confusion, Agitation, Restlessness HPI: Ms. Peters is a 70 y.o. Caucasian, female with known PmHx of Dementia, who presents to the office by her son. The son reports a 2-day history of worsening confusion, agitation and restlessness compared to her baseline. Son also reports a doctor visit 3 day ago with an increase in HCTZ to 50mg d/t HTN. Subjective history is obtained from her son as she is a poor historian.  Current Medications:  Multivitamin daily  Losartan 50mg daily  HCTZ 50mg daily  Fish Oil 1 tablet daily  Glyburide 5mg daily  Metformin 500mg BID  Donepezil 10mg daily  Alendronate 70mg orally once a week Allergies: Atorvastatin- myalgias PMHx: HTN, T2DM, Osteoporosis, Chronic Allergic Rhinitis. Recommended age-appropriate immunizations current. Last Tetanus booster 7 years ago. Last seen by physician 3 days ago. Soc and Substance Hx: Ms. Peters is a widow of 12 years and a retired teacher of 35 years. Never smoker, occasional drinker of 1 6oz. glass of wine per night. Lives with her son, daughter-in-law and two grandchildren. Enjoys water aerobics 2 times per week. Fam Hx: Mother- Deceased 87 y.o. from CVA. Hx of Osteoporosis & HTN. Father- Deceased 89 y.o. from MI. Hx of HTN, T2DM per son. Paternal/Maternal grandparents deceased- unknown age/medical Hx per son. Sister- 76 y.o., living, Hx. HTN, Breast CA. Brother- 66 y.o. Hx. HTN, HLD, T2DM. Granddaughter- 17 y.o., Asthma. Grandson- 11 y.o., No known PmHx. Surgical Hx: Hysterectomy- 1993, Cholecystectomy- 1989 Mental Hx: Dementia- Donepezil 10mg daily. Denies current SI/HI. Denies auditory or visual hallucinations. No past Hx of SI/HI. Recent increase in confusion, agitation, restlessness. Last Mini-Mental State Exam (MMSE) score 18/30. Violence Hx: Reports feeling safe at home. Denies current physical, mental, financial abuse. Denies past Hx of abuse. This study source was downloaded by from CourseH on :47:56 GMT -06:00 Reproductive Hx: Unknown LMP. Hysterectomy- 1993. Denies current sexual activity. ROS (review of symptoms): GENERAL: Vital Signs: 98.1 120/64 HR-72 20. Denies fever, chills, weight loss and/or fatigue. HEENT: Eyes: Denies recent changes in or loss of vision. Denies new or recent blurred or double vision. Denies jaundiced sclera. Denies abnormal drainage. Ears, Nose, Throat: Denies changes in or loss of hearing. Denies tinnitus. Denies abnormal drainage. Positive Chronic Allergic Rhinitis. SKIN: Denies changes in skin. No rashes. No Lesions. No open or unhealing wounds. CARDIOVASCULAR: Denies chest pain or palpitations. Denies peripheral edema. RESPIRATORY: Denies cough. Denies SOB or difficulty breathing. Denies orthopnea. Denies PND. Denies wheezing. GASTROINTESTINAL: Denies N/V/D. Denies abd pain. Denies recent weight loss or anorexia. Denies dietary changes. Denies changes in bowel habits. GENITOURINARY: Denies changes or difficulty with urination. Denies dysuria, frequency, or urgency. Denies urinary incontinence. NEUROLOGICAL: Denies HA. Denies syncope. Denies dizziness. Denies paresthesias. Acute increase in confusion, agitation and restlessness. Positive ataxia. MUSCULOSKELETAL: Denies bone or muscle pain. Denies Falls. Denies Decrease ROM. HEMATOLOGIC: Denies abnormal bleeding or bruising. LYMPHATICS: Denies painful or enlarged lymphnodes. PSYCHIATRIC: Denies current or past SI/HI. Denies anxiety and depression. Positive dementia. Current Aricept 10mg Daily. Positive acute increase in confusion, agitation and restlessness. ENDOCRINOLOGIC: Denies weight loss and/or weight gain. Denies polydipsia. Denies polyuria. Denies excessive sweating. REPRODUCTIVE: Post-Menopausal. LMP unknown. Positive hysterectomy 1993. Denies abnormal vaginal bleeding or discharge. Denies current sexual activity. ALLERGIES: Denies food allergies. Positive allergic rhinitis. Positive allergy to Atorvastatin- Myalgias. O (objective) Physical exam: General: Well groomed. Well-nourished. NAD. Vital Signs: 98.1 120/64 HR-72 20. Alert but easily distracted. Eye contact fair.