Case Study Assignment: Assessing Neurological Symptoms
A 70-year-old female comes to your clinic with complaints of forgetfulness. She noticed it about a year ago and it has progressively gotten worse. She sometimes forgets what she is going to do when she gets to another room. Her family has noticed the problem with her forgetfulness, but she is still able to manage her finances and drive, per her report.
The Case Study Assignment
Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis and justify why you selected each.
Solution
Episodic/Focused SOAP Note
Patient Information:
Initials: S.T. Age: 70 years Sex: Female Race: Hispanic
S
CC (chief complaint): “I have forgetfulness.”
HPI: S.T. is a 70-year-old Hispanic female who has visited the clinic accompanied by her daughter. Her chief complaint is forgetfulness. She reports that her symptoms began a year ago, but they have gotten worse over the years. S.T. further indicates that she sometimes forgets what she is going to do when she gets to another room. According to her daughter, the family has noticed the problem with their mother’s forgetfulness. However, she is still able to manage her finances and drive.
Location: Psychological
Onset: 1 year ago
Character: Abstract
Associated signs and symptoms: Not indicated
Timing: Anytime
Exacerbating/ relieving factors: None mentioned
Severity: Mild
Current Medications: None
Allergies: No known drug or food allergies reported.
PMHx: S.T. is unable to remember childhood immunization history. She received Johnson & Johnson COVID-19 vaccine on 12/06/2021. She received her last tetanus vaccine 8 years ago in April 2014, but she cannot recall the date. S.T. reports a history of hospitalization which happen in her late 40s due to pneumonia complications.
Soc Hx: S.T. is a retired high school teacher. Her husband is an engineer. She denies cigarette or alcohol consumption. She hardly engages in exercise. S.T. spends a part of the day on the farm. She uses her car in case she wants to go to town. She eats a lot of fruits and vegetables and hardly eats red meat. Family members have reported a problem with her forgetfulness.
Fam Hx: S.T. reports that her father and mother died several years ago from stroke and a cardiovascular complication respectively. She denies the presence of a chronic condition among the living members of her family.
ROS:
GENERAL: Denies fever, abnormal changes in weight, reports forgetfulness.
HEENT: Does not report a recent head injury, visual loss, ear pain, nasal congestion, or sore throat.
SKIN: Does not report itchiness or rashes.
CARDIOVASCULAR: No chest discomfort or pain reported.
RESPIRATORY: No shortness of breath or cough reported.
GASTROINTESTINAL: Denies abdominal pain or discomfort.
GENITOURINARY: Denies a burning sensation in the genitalia during urination.
NEUROLOGICAL: Reports forgetfulness or memory loss. Denies tingling or numbness of the extremities.
MUSCULOSKELETAL: Denies joint-related pain or a problem with gait.
HEMATOLOGIC: Denies a history of blood disorders.
LYMPHATICS: Does not report pain or swelling of the lymphatics.
PSYCHIATRIC: No anxiety reported. Denies stress. Reports forgetfulness or memory loss.
ENDOCRINOLOGIC: Denies abnormal sweats at night.
ALLERGIES: No drug or food allergies reported.
O.
Vital signs: Temperature: 98 degrees Fahrenheit, blood pressure: 121/80, respiratory rate: 18 breaths per minute, heart rate: 92 beats per minute, weight: 152.7 lb, height: 5.8 feet, BMI: 23.2 kg/m2.
General appearance: S.T. is also properly oriented to person, place, and time.
Skin: Warm, hairy, and no lesions
HEENT: Head is normocephalic and lacks physical injury. Visual acuity is 20/20, no evidence of blockage or discharge in the ears, no evidence of nasal congestion, and evidence of a non-erythematous throat.
Neck: Lacks evidence of swelling or pain.
Chest: No wheezes or rhonchi.
Heart: Absence of murmur or gallop. Capillary refill is less than 3 seconds.
Abdomen: Evidence of abdominal tenderness absent.
Back/spine: Deformities absent.
Extremities: No evidence of joint pain.
Genitalia/Rectal: Female genital organs present.
Neurologic:
Mental status: S.T. presents with forgetfulness. She has a normal speech.
Cranial nerves: Intact with evidence of visual fields.
Motor: Muscle strength on all joints is 5/5.
Sensory: Normal sensitivity in upper and lower limbs.
Diagnostic results: S.T. has never visited the clinic and no mental tests have been conducted (Bickley et al., 2020; Dains et al., 2019).
A.
Differential Diagnoses
- Subjective cognitive decline (Jessen et al., 2020)
- Mild cognitive impairment
- Age-associated memory impairment
- Amnesia
- Dementia (McCollum & Karlawish, 2020; Yoon et al., 2018)
References
Bickley, L., Szilagyi, P., Hoffman, R., & Soriano, R. (2020). Bate’s guide to physical examination and history taking (Lippincott Connect). 13th ed. Philadelphia: Wolters Kluwers.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Jessen, F., Amariglio, R. E., Buckley, R. F., van der Flier, W. M., Han, Y., Molinuevo, J. L., Rabin, L., Rentz, D. M., Rodriguez-Gomez, O., Saykin, A. J., Sikkes, S., Smart, C. M., Wolfsgruber, S., & Wagner, M. (2020). The characterisation of subjective cognitive decline. The Lancet. Neurology, 19(3), 271–278. https://doi.org/10.1016/S1474-4422(19)30368-0
McCollum, L., & Karlawish, J. (2020). Cognitive impairment evaluation and management. The Medical clinics of North America, 104(5), 807–825. https://doi.org/10.1016/j.mcna.2020.06.007
Yoon, P. S., Ooi, C. H., & How, C. H. (2018). Approach to the forgetful patient. Singapore Medical Journal, 59(3), 121–125. https://doi.org/10.11622/smedj.2018026