Case 5 History and Physical

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HISTORY AND PHYSICAL EXAMINATION

Patient Name: Fanny Copeland

Patient ID: 115463DOB: 10/26/- - - -Age: 58Sex: Female

Room No.: Hillcrest Memory Diagnostic Center

Date of Admission/Date of Arrival: 04/26/- - - -

Referring Physician: Lyndon F. Talcott, MD, Neurology

Admitting Diagnosis: Memory loss.

BACKGROUND: Ms. Copeland is a 58-year-old left handed white female who was referred to the Hillcrest memory Diagnostic Center by the emergency room physician for evaluation of memory problems and difficulties in functioning including suicidal ideations.

MEDICAL HISTORY: Includes osteoarthritis, frequent urinary tract infections, hysterectomy 20 years ago, and some TMJ (The temporomandibular joint) problems. There is no history of TBI (traumatic brain injury) or LOC (Level of consciousness) but the patient reported that she had hit her head on the right side creating her TMJ problems. She denies ETOH (Ethanol) intake or smoking. Current medicines include: ibuprofen and Detrol. On admission to the MDC (Memory Diagnostic Center) the patients score on the MMSE was 3-D over 3-D and she was able to recall all three words. Clinical dementia rating was 1. Score on the geriatric depression scale was 12. For further information please refer to patients medical records. Ms. Copeland has a high school education with some college course work. She has worked for about 30-years as an editor. Currently she resides in her own home with her granddaughter with is sixteen. The patient’s granddaughter Jance, moved in about 3-years-ago and has had academic problems and reduced moderation. Ms. Copeland has tried counseling and the Date Counting Learning Center without much success secondary to Jance’s reduced communication and tendencies to sabotage own successes . Ms. Copeland is under considerable stress and does not know for sure if her problems with her memory have worsened. Ms. Copeland indicated that she has noticed memory problems for about 5-years with a mild gradual worsening. She reported that she has naming problems and some forgetfulness, such that she may misplace items at times. Ms. Copeland indicated that her daily activities include housekeeping, cooking and occasional use of home computer but very little other enjoyable activities. She uses a pocket calendar and she reportedly is forgetful of events and conversations. The patient denied depression but reported a long-term sleep disorder. She believes she has not lost interest in things but her activities have declined because she believes she’s so busy. She has been president of her professional association and has had problems recalling people’s names. She continues to drive. She has had no difficulties with this, however she finds she drives “automatic” where she thinking about other things and then cannot recall the trip.

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HISTORY AND PHYSICAL EXAMINATION

Patient name: Fanny Copeland
Patient ID: 115463
Date of Admission: 04/26/- - - -
Page 2

REASON FOR REFFERAL AND ASSESMENT RATIONAL: This patient was referred by the ER physician for evaluation of her cognitive and emotional status to assist with diagnostics and determine brain function as part of a medically necessary evaluation. In addition, the evaluation was requested in order to determine her ability to make informed decisions, follow safety information, and remembering information provided by others. This was asset using neuropsychological and dementia screen evaluations and structured behavioral observations. In addition, a clinical interview was used to ascertain emotional status and adjustment. This assessment was also requested for the purpose of assisting in treatment planning and provision of resources.

PROCEDUERS: MMPI (Minnesota Multiphasic Personality Inventory), Mattis Dementia Rating Scale, Wechsler Logical Memory, Trail Making Test Parts A and B, neuropsychological evaluation, clock drawing, structured...
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