SOAP Note for Parkinsons's Disease

SOAP Note
Name
Institutional Affiliate
SOAP Note
Patient Information:
Initials: Mr. P Age: 68 Sex: M Race: African American
Subjective
Mr. P says that he is experiencing muscle rigidity, difficulty maintaining balance when he tries to walk, and tremor episodes.
CC (Chief Complaint)
The patient complains of rigidity of muscles, tremors on his fingers, difficulty maintaining balance while walking, and imbalanced posture.
HPI (History of Present illness)
Mr. P is a 68-year-old African American man who presented at the clinic with complaints of muscle rigidness characterized by stiffness of the hands, feet, and joints. He finds it hard to drive and can only move around with the help of his daughter, who helps take care of him. He also claims to have experienced difficulties moving around in the past two weeks, with his daughter raising concerns about his recent posture imbalance in the same duration. He also noticed resting tremors in his hands.
History
The patient has no history of major or chronic illness, with no known allergies to food or drugs. He has no prior hospitalizations for chronic illnesses or surgical procedures and no history of mental health problems. There is no documentation of any medication intolerance, and he is currently under no medication. The patient’s grandfather was diagnosed with Parkinson's disease, and his siblings have no history of chronic disease or condition. He is a retired high school teacher currently running a local laundry service in the neighborhood with the help of his daughter. He is trying to quit smoking after 15 years of engaging in the habit and occasionally drinks during family or celebratory events with friends.
ROS (Review of Systems)
General: There is no weight loss, fatigue, fever, or chills.
Skin: No itching or rashes.
HEENT: Patient has no blurred vision, running nose, or reduced visual acuity.
Ca...