Case 5 History and Physical Essay

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HISTORY AND PHYSICAL EXAMINATION Patient Name: Fanny Copeland Patient ID: 115463 DOB: 10/26/- - - - Age: 58 Sex: 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)…show more content…
BEHAVIORAL OBSERVATIONS: Ms. Copeland was alert and co-operative during the interview. During testing she appeared to motivated to perform optimally on all tasks. Her frustration tolerance was moderate. She seemed somewhat sullen, incurred during the initial portions of the testing but became more relaxed with the examiner as testing proceeded. ATTENTION AND CONCENTRATION: Mildly impaired ability to generate and maintain sufficient attention for tasks completion with queuing and redirection. Mild impulsivity was noted during the testing. ORINTATION: Ms. Copeland was oriented to person, place and time. She was able to describe the reason for the evaluation. COGNITION, REASONING AND JUDGMENT: The patients score of 136 and the Dementia Rating Scale was within normal limits. Ability to obstruct commonalities on simple verbal analogies was unremarkable. Ability to determine same different relationships in geometric design was mildly impaired. Simple Arrhythmia Sequencing was unremarkable while Complex Residence Sequencing revealed one error of sequence but she was able to return to the appropriate sequence without guidance. Ability to determine appropriate solutions to basic problem solving in areas in simple hypothetical emergency situations was unremarkable. Cognition declines only mildly as information length and complexity increase. Performance improves within tasks structure. ACADEMIC: Calculation was unremarkable for simple
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