Care Across the Lifespan Il

Soap note

Pt Name: A.G Age: 79 Years old. Diagnosis: Depression Chief Complain:Having memory issues. Pt is a 79 year old male, who presented to the clinic with the issue of memory loss. Pt complained that he is having problem with the spouse because of his inability to remember what happened in the past. The wife as well questions every thing that he doses believing that he dose not accept her views. This is creating a big problem between them. When asked if is seeing a therapist , he said yes but added that the wife also needs to see a therapist but she thinks she dose not need one. Pt believes he is not depressed and is doing well with his medications. He is encouraged to continue taking his medications and also to continue seeing his therapist in order not to get overwhelmed with the issues going on at home. Pt is on Wellburtrin 200 mg, Trazadone 50 mg, Primidone 100 mg. Pt is asked to come back to the clinic in 3 months for follow up.