Posted: July 30th, 2023

Episodic/Focused SOAP Note: Assessing Cognitive Impairment in an Elderly Patient

Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.
With regard to the case study you were assigned:
• Review this week’s Learning Resources, and consider the insights they provide about the case study.
• Consider what history would be necessary to collect from the patient in the case study you were assigned.
• Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
• Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
THE CASE STUDY ASSIGNMENT
Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.

Case Study 2: Forgetfulness
Asia brings her 67-year-old father into the office stating he is very forgetful. He has lost his car keys several times. She also states he has driven to the store and called her asking for directions to get back home.

Episodic/Focused SOAP Note: Assessing Cognitive Impairment in an Elderly Patient

Patient Information:
Name: Mr. John Doe (pseudonym)
Age: 67 years
Presenting Complaint: Forgetfulness, losing car keys, disorientation

Subjective Findings:
Asia, the patient’s daughter, brings her 67-year-old father, Mr. John Doe, to the office, expressing deep concern about his persistent forgetfulness. She reports incidents of him misplacing his car keys on multiple occasions, which has led to moments of anxiety and confusion for both Mr. Doe and herself. More alarmingly, she recounts a concerning incident where her father drove to a nearby store but became disoriented and had to call her for directions to return home safely.

History Taking:
To comprehensively assess Mr. Doe’s condition, it is imperative to conduct a detailed history taking. Essential components of the history include information about any preexisting medical conditions, previous cognitive health, family history of neurological disorders, current medications, and recent life events that might have contributed to the cognitive changes.

Physical Examination and Diagnostic Tests:
A thorough physical examination is necessary to rule out any underlying medical conditions that could be contributing to Mr. Doe’s forgetfulness. Specific attention should be given to neurological examinations, evaluating cognitive functions, motor skills, reflexes, and sensory responses.

In addition to the physical examination, certain diagnostic tests can aid in establishing a more accurate diagnosis. Magnetic Resonance Imaging (MRI) or Computed Tomography (CT) scans of the brain can help identify structural abnormalities or signs of cerebral atrophy that might indicate neurodegenerative disorders. Additionally, cognitive assessment tools like the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA) can provide valuable insights into cognitive impairments and track changes over time.

Differential Diagnosis:
Considering the nature of Mr. Doe’s presentation, several potential conditions must be included in the differential diagnosis. Five plausible conditions to consider are:

Alzheimer’s Disease: This neurodegenerative disorder is characterized by progressive memory loss, cognitive decline, and difficulties in daily functioning. The age of onset and the pattern of forgetfulness align with the possibility of Alzheimer’s disease.

Vascular Dementia: Vascular dementia results from impaired blood flow to the brain, leading to cognitive decline. Given the patient’s age and the occurrence of disorientation, this condition warrants consideration.

Mild Cognitive Impairment (MCI): MCI is a transitional stage between normal aging and dementia, and individuals with MCI have a higher risk of developing Alzheimer’s disease. Assessing for MCI is crucial in predicting future cognitive decline.

Frontotemporal Dementia: This type of dementia affects the frontal and temporal lobes of the brain, leading to changes in behavior, personality, and language. Some cases of frontotemporal dementia can present with memory problems.

Depression: Severe depression can manifest as cognitive impairment and memory difficulties, often referred to as “pseudodementia.” Evaluating the patient for depression is crucial, as it may be an underlying cause of his symptoms.

Conclusion:
In conclusion, Mr. Doe’s forgetfulness and disorientation necessitate a comprehensive assessment to determine the underlying cause accurately. A detailed history, thorough physical examination, and appropriate diagnostic tests, such as MRI or CT scans, and cognitive assessments, can aid in reaching a definitive diagnosis. The differential diagnosis should encompass conditions such as Alzheimer’s disease, vascular dementia, mild cognitive impairment, frontotemporal dementia, and depression, considering the patient’s age, symptoms, and clinical profile.

References:

Alzheimer’s Association. (2022). Alzheimer’s disease facts and figures. Alzheimer’s & Dementia, 18(4), 313-373.

Petersen, R. C. (2016). Mild cognitive impairment. Continuum (Minneapolis, Minn.), 22(2 Dementia), 404-418.

Sachdev, P. S., Blacker, D., Blazer, D. G., Ganguli, M., Jeste, D. V., Paulsen, J. S., … & Sullivan, E. V. (2014). Classifying neurocognitive disorders: The DSM-5 approach. Nature Reviews Neurology, 10(11), 634-642.

Sachdev, P. S., & Valenzuela, M. J. (2016). Brain imaging in the diagnosis of Alzheimer’s disease. Neurology, 86(24), 2270-2272.