Copeland Case 5 Consultation

Topics: Medical history, Alzheimer's disease, Memory Pages: 3 (502 words) Published: February 29, 2012
Patient Name: Fanny Copeland

Patient ID: 115463

Date of Birth: 10/25/----

Age: 58

Sex: Female

Room Number: Hillcrest Memory Diagnostic Center

Consultant: Lyndon F.Talcott, MD Neurology

Requesting Physician: Stella Rose Dickinson, PhD Psychology

Date of Consult: 04/28/----


HISTORY: Ms. Copeland is a very pleasant 58-year-old white female who gives a history of several years of what she calls short-term memory problems. She has had no long-term deficits. No family history of dementia. Denies head injuries specifically the loss of consciousness although she did have a blow to the head four years ago. She has had no strokes, denies any current sensory or motor loss. She had a single seizure back about 30 years ago without recurrence. MRI scan done at that time was apparently negative.

PAST MEDICAL/SURGICAL HISTORY: Her past medical history is remarkable for a single seizure. Migraine x 1, some 12 years ago. DJD urinary bladder spasms. She has had a previous tonsillectomy, appendectomy, hysterectomy, bilateral salpingo-oophorectomy.

ALLERGIES: Has a reaction to tetracycline. But no true drug allergies.

MEDICATIONS: Estrodiol, Detrol, ibuprofen, vitamin E, and multivitamins.

PHYSICAL EXAMINATION: Revealed a pleasant but depressed appearing female who is over weight but in no acute distress. She wears a brace on her right wrist. Height is 5 feet 7 inches. Weight 252 pounds. Temperature 98°F. Pulse 80. Respiratory rate 20. Blood pressure 140/80. She has not carotid bruits or meningismus. Cranial nerves 2 through 12 are intact and detailed to include visual fields. Funduscopic exam and pupillary examination. Motor exam reveals 5 out of 5 strength in arms and legs without atrophy or vesiculation. Reflexes are trace over four. Sensory exam is negative and nonfocal.


Patient Name: Fanny Copeland
Patient ID: 115463
Date of Consult: 04/28/----

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