ASSESSMENT 8 PATIENT NOTE: CONFUSION AND MEMORY LOSS HISTORY: Describe the history you just obtained from

this patient. Include only information (pertinent positives and negatives) relevant to this patients problem(s). HPI: 57 YO M C/O CONFUSION AND MEMORY LOSS FOR 2 MONTHS. PATIENT REPORTS PROGRESSIVE DIFFICULTY REMEMBERING HOW TO GET HOME FORM THE MARKET, WHERE HE PUT HIS KEYS AND FORGETS TO SHUT THE STOVE OFF. DIFFICULTY WITH BATHING, FEEDING, GETTING UP FROM A CHAIR, SHOPPING, COOKING AND PAYING BILLS. DECREASED CONCENTRATION, DEPRESSION DUE TO RECENT MEMORY LOSS. PATIENT REPORTS FEELING LIGHTHEADED WHEN GETTING UP QUICKLY. ROS: NEGATIVE EXCEPT AS NOTED ABOVE ALLERGIES:NONE MEDICATIONS:HYDROCHLOROTHIAZIDE, HEART MEDICATIONS DOES NOT RECALL THE NAME PMH: DIAGNOSED WITH HYPERTENSION MANY YEARS AGO, HEART ATTACT 5 YEARS AGO PSH:VASECTOMY 15 YEARS AGO FH: PARENTS ARE DECEASED FOR MANY YEARS AND THEY WERE HEALTHY SH: DENIES TOBACCO, ETOH, OR DRUG USE, LIVES WITH DAUGHTER, WIDOWER, RETIRED SCHOOL TEACHER, NOT SEXUALLY ACTIVE SINCE DEATH OF HIS WIFE. SUPPORT SYSTEM:PATIENT REPORTS HAVING MANY FRIENDS, AND LIVES WITH HIS DAUGHTER WHO CARES FOR HIM ON A DAILY BASIS. PHYSICAL EXAM: Describe any positive and negative findings relevant to this patients problem(s). Be careful to include only those parts of examination you performed in this encounter. PATIENT IS ANGRY AND RESTLESS AND HIS VITALS ARE WITHIN NORMAL LIMITS. HIS HEENT APPEARS NORMOCEPHALIC AND ATRAUMATIC. HIS NECK IS SUPPLE WITH NO JVD, LYMPHADENOPATHY AND THYROID IS WITHIN NORMAL LIMITS. HIS BREATH SOUNDS ARE CLEAR TO AUSCULTATION BILATERALLY. HIS HEART SOUNDS ARE NORMAL S1/S2. HE IS ALERT TO PERSON, PLACE AND TIME ON NEUROLOGICAL EXAM. HIS CN 2-12 ARE INTACT AND MOTOR STRENGTH IS 5/5 IN EXTREMITIES EXCEPT FOR LEFT ARM. HIS REFLEXES ARE SYMMETRIC AND INTACT THROUGHOUT AND SENSATION TO DULL AND PIN PRICK INTACT THROUGHOUT. HIS GAIT IS NORMAL WITH NEGATIVE ROMBERG. THERE IS NO CYANOSIS OR BRUISING IS NOTED IN THE EXTREMITIES EXCEPT A WEAK LEFT FOREARM. DATA INTERPRETATION: Based on what you have learned from the history and physical examination, list up to 3 diagnoses that might explain this patients complaint(s). List your diagnoses from most to least likely. For some cases. Fewer than 3 diagnoses will be appropriate. Then, enter the positive or negative findings from the history and physical examination (if present) that support each diagnosis. Lastly, list initial diagnostic studies (if any) you would order for each listed diagnosis (e.g. restricted physical exam maneuvers, laboratory tests, imaging, ECG, etc.

Diagnosis #1: ALZHEIMERS DISEASE HISTORY FINDING(S) -CONFUSION AND MEMORY LOSS FOR 2 MONTHS -DIFFICULTY DOING DAILY ACTIVITIES -DEPRESSION AND DECREASED CONCENTRATION Diagnosis #2: VASCULAR DEMENTIA HISTORY FINDING(S) -CONFUSION AND MEMORY LOSS FOR 2 MONTHS -DEPRESSION AND DECREASED CONCENTRATION -DIFFICULTY DOING DAILY ACTIVITIES Diagnosis #3: VITAMIN B12 DEFICIENCY HISTORY FINDING(S) -CONFUSION AND MEMORY LOSS FOR 2 MONTHS -DEPRESSION AND DECREASED CONCENTRATION -DIFFICULTY DOING DAILY ACTIVITIES Diagnostic Studies: -CBC -ELECTROLYTES -CALCIUM GLUCONATE -SERUM B12 LEVELS -CT HEAD

PHYSICAL EXAM FINDING(S) -PATIENT IS ANGRY AND RESTLESS -ALERT AND ORIENTED TO TIME PLACE AND PERSON -WEAKNESS OF LEFT FOREARM

PHYSICAL EXAM FINDING(S) -PATIENT IS ANGRY AND RESTLESS -ALERT AND ORIENTED TO TIME PLACE AND PERSON -WEAKNESS OF THE LEFT FOREARM

PHYSICAL EXAM FINDING(S) -PATIENT IS ANGRY AND RESTLESS -ALERT AND ORIENTED TO TIME PLACE AND PERSON -WEAKNESS OF THE LEFT FOREARM