General weakness and functional decline
Complete SOAP example
Example narrative
87-year-old woman from AL, normally walks to meals with rollator, reports three days of weakness and reduced appetite. Staff report new transfer assistance and mild confusion. Denies focal weakness, chest pain, vomiting or fall.
Primary survey intact. Patient found seated on bed, awake but slower than baseline. Serial vitals, temperature, BGL and focused neurologic findings obtained. Mucosa dry; no focal deficit or injury. Medication and care records reviewed.
Differential considerations: 1) infection with delirium, 2) dehydration or electrolyte disturbance, 3) medication adverse effect. Acute functional decline without a confirmed cause.
Monitoring and supportive care provided per findings. Mobility was not tested unsafely; cognition, perfusion and symptoms reassessed. Transported with baseline function, collateral source, goals-of-care information and current change clearly communicated.