Week 3: Sophia King
79 y/o
5′ 4″ (163 cm)
110.0 lb (50.0 kg)
Reason for encounter
Confusion and memory loss reported by family member
Location
Outpatient clinic with x-ray, ECG, and laboratory capabilities
Interview History Questions for Sophia King/ Janet Riley
- Does she feel she has more memory problems than others (witness)
- How severe are her memory problems (witness)
- Do you have trouble with reasoning, planning, or organizing (patient)
- Is she having trouble concentrating or making decisions well? If so, how often (witness)
- Are you having trouble concentrating or making decisions well? If so, how often (patient)
- When did her trouble concentrating or making decisions start (witness)
- Over the past two weeks, how often has she been bothered by feeling down, depressed, or hopeless? (witness)
- Over the past two weeks, how often has she been bothered by having little interest or pleasure in doing things (witness)
- ………….
Physical Exams Required
- Weight
- Height
- cognitive status
- SpO2
- temperature
- blood pressure
- pulse
- respiration
- temperature
- auscultate heart
- auscultate lungs…….
Differential Diagnoses
- Dementia, Alzheimer’s
- Dementia, vascular
- Major depressive disorder
- Encephalopath
- ………
Get all the complete case with history questions, physical exam, complete EHR documentation, exercises, case findings, diagnosis, test results, and management plan.
Diagnosis: Alzheimer’s disease (moderate) with possible vascular component
Diagnostic Tests:
- Brain MRI: generalized cortical atrophy, reduced hippocampal volume R>L, no evidence of infarctions
- Complete blood count: normal
- Comprehensive metabolic panel: normal
- Folate: normal
- Free T4: normal
- HIV: negative
- …………..
