NURS 6665 Week 7 Assignment 2 Focused SOAP Note and Patient Case Presentation Essay

NURS 6665 Week 7 Assignment 2 Focused SOAP Note and Patient Case Presentation Essay

NURS 6665 Week 7 Assignment 2 Focused SOAP Note and Patient Case Presentation Essay


CC (chief complaint): ‘My grandfather has become highly irritable and forgets things easily.’

HPI: Mr. Jacobs is a 68-year-old male that was brought to the clinic today for assessment. Her daughter brought him with complaints that he has been highly irritable for the past months and began wandering a few weeks ago. The daughter reported that the symptoms were initially mild but have been progressing over time. The accompanying symptoms reported during the assessment included poor judgment, difficulty in decision-making, loss of initiative, failing to completing tasks such as those related to daily living, and losing things. The daughter also noted that her grandfather has been experiencing increased anxiety over the last few weeks. The precipitating factors for the symptoms included his engagement in activities that require mental straining such as making decisions and doing math-related tasks. She denied any recent illness that could be attributable to the problem.

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Substance Current Use: The daughter reported that her grandfather was a smoker until the age of 60 years when he quit. He occasionally takes alcohol. She estimated that he drinks 3-4 bottles a week.

Medical History: The daughter reported that her grandfather has a history of hospitalization due to pneumonia when he was 55 years. He has no history of surgery.

  • Current Medications: Mr. Jacobs currently uses over the counter Tylenol for occasional joint pains.
  • Allergies: The daughter denied any history of allergies
  • Reproductive Hx: Non-contributory


  • GENERAL: The patient appeared appropriately dressed for the occasion. He was slightly underweight for his age. He denied fatigue, fever, and chills. His orientation was grossly altered.

HEENT: Eyes: The patient denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: The patient denies hearing loss, sneezing, congestion, runny nose, or sore throat.

  • SKIN: The patient denies skin rash or itchiness
  • CARDIOVASCULAR: The patient denies chest pain, discomfort, chest pressure, palpitations, or edema.
  • RESPIRATORY: The patient denies shortness of breath, cough, or sputum
  • GASTROINTESTINAL: The patient denies nausea, vomiting, anorexia, or diarrhea. He also denied abdominal pain or diarrhea.
  • GENITOURINARY: The patient denies burning urination, increased urgency or frequency, and hesitancy
  • NEUROLOGICAL: The patient denies headache, syncope, dizziness, ataxia, paralysis, numbeness, or tingling in the extermities,
  • MUSCULOSKELETAL: The patient denies back pain, muscle and joint stiffness
  • HEMATOLOGIC: The patient denies anemia, bruising, or bleeding
  • LYMPHATICS: The patient denies lymphadenopathy or any history of splenectomy
  • ENDOCRINOLOGIC: The patient denies cold or heat intolerance, polyuria, polydipsia, and polyphagia.


Diagnostic results: Brain imaging such as CT scan are needed to rule out any disorders such as the presence of tumors, which might be contributing to the client’s problems.


Mental Status Examination: The patient was dressed appropriately for the occasion. He appeared slightly underweight for his age. He was not oriented to place and others. His orientation to self was intact. He demonstrated significant irrirability when asked mentally tasking questions. He denied illusions, delusions, and hallucinations. His thought process was altered. His affect was flat. He demonstrated mild difficulties in self-expression. He denied suicidal thoughts, plans, or intention.

Diagnostic Impression: Mr. Jacobs’ primary diagnosis is Alzheimer’s disease. Alzheimer’s disease is a neurocognitive disorder characterized by a significant decline in cognitive functioning. The disorder is largely prevalent in the elderly populations. Patients often experience symptoms that include memory loss, poor judgment, lack of spontaneity, getting lost, losing things, anxiety, agitation, and mood and personality changes. Patients also have short attention spans, forget friends and family members, make repetitive statements, and experience delusions, hallucinations, and paranoia (Kumar et al., 2022). Mr. Jacobs exhibit most of these symptoms, hence, Alzheimer’s disease is his primary diagnosis.

            Mr. Jacobs’ secondary diagnosis is vascular dementia. Vascular dementia is a type of dementia characterized by symptoms that include slowed thought processes, troubles in understanding others, difficulty in concentration, and planning. However, it is the least likely diagnosis for Mr. Jacobs since patients with vascular dementia do not have impaired memory and language. Intead, the processes are mainly slowed. The other differential that should be considered for the patient is polypharmacy. Elderly patients are increasingly at a risk of developing symptoms related to Alzheimer’s disease if they use several drugs with increased risk of interractions (Dubois et al., 2021). As a result, the psychiatric mental health nurse should perform a comprehensive history to determine if the patient is currently on prescribed medications that could be contributing to the problem.

Reflections: I believe that I developed the accurate diagnosis for the patient in this case study. I utilized nursing concepts and skills such as physical examination and comprehensive history taking. I also utilized the DSMV to determine the client’s most accurate diagnosis. Alzheimer’s disease affects the patient’s health and wellbeing. It also affects their ability to engage in activities of daily living. As a result, I ensured that her daughter was informed about the care that Mr. Jacobs needs for his optimal functioning and wellbeing.

Case Formulation and Treatment Plan: A head CT scan was ordered to rule out any other potential causes of Mr. Jacobs’ health problems. The patient was prescribed Aducanumab 10 mg/kg intravenously after every 4 weeks, at least 21 days apart (Mintun et al., 2021). The family was referred to Alzheimer’s social support groups in the community. The daughter was educated about the care needed by her father. This included maintaining normal routines as possible, avoiding rushing activities, monitoring him for risk of injuries, and ensuring home environment safety (Breijyeh & Karaman, 2020). They were booked for a follow-up visit after four weeks to assess his response to treatment.


Breijyeh, Z., & Karaman, R. (2020). Comprehensive Review on Alzheimer’s Disease: Causes and Treatment. Molecules, 25(24), Article 24.

Dubois, B., Villain, N., Frisoni, G. B., Rabinovici, G. D., Sabbagh, M., Cappa, S., Bejanin, A., Bombois, S., Epelbaum, S., Teichmann, M., Habert, M.-O., Nordberg, A., Blennow, K., Galasko, D., Stern, Y., Rowe, C. C., Salloway, S., Schneider, L. S., Cummings, J. L., & Feldman, H. H. (2021). Clinical diagnosis of Alzheimer’s disease: Recommendations of the International Working Group. The Lancet Neurology, 20(6), 484–496.

Kumar, A., Sidhu, J., Goyal, A., & Tsao, J. W. (2022). Alzheimer Disease. In StatPearls. StatPearls Publishing.

Mintun, M. A., Lo, A. C., Duggan Evans, C., Wessels, A. M., Ardayfio, P. A., Andersen, S. W., Shcherbinin, S., Sparks, J., Sims, J. R., Brys, M., Apostolova, L. G., Salloway, S. P., & Skovronsky, D. M. (2021). Donanemab in Early Alzheimer’s Disease. New England Journal of Medicine, 384(18), 1691–1704.

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NURS 6665 Week 7 Assignment 2 Instructions

Assignment 2: Focused SOAP Note and Patient Case Presentation
Please do assignment on a neurocognitive disorder of an elderly patient.

Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Focused SOAP notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.

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