Assignment 2: Focused SOAP Note and Patient Case Presentation

Mental Status Examination:

The patient is who is 70 years old who is forgetting things withing a short time which

seem to be dementia and mood disorder. Since she has been working in the military for over 20 years,

her condition is mainly associated with her worrying experiences and traumatic events in the

warzone. She looks very presentable and smartly dressed thus her general appearance looks good

She is communicating so well with a clear speech, report gets frustrated when she cannot remember things, alert to self and place disoriented to time, confused. She denies hallucination.

despite being previously hospitalized for dementia and depression. However, she gets disrupted at

some point during the conversation. Judgment is impaired, affect labile mood stress and anxious, can not care for self, behavior cooperative and disorganized, thought process tangential, thought content preoccupation, denies SI/HI,