28 Dec Based on this information,

MSN610 Diagnostic Reasoning and Advanced Physical Assessment

Module 6 Discussion

Case Study 6

CC: 85 year old female presents to your exam room with “memory loss”

HPI: J.B. is brought in with her son who states his mom is forgetting to pay her bills over the last 4 months and “gets lost” in her own home. J.B. admits she sometimes gets “forgetful”. Her previous PCP retired 6 months ago and they have no medical records with them.

PMH: Total Abdominal Hysterectomy 20 years ago. G3P2 1 Miscarriage. No other surgeries or hospitalizations. Treated for HTN, A-fib

Medications: HCTZ 25 mg daily Allergies: None

Digoxin 0.25 mg daily

Coumadin 1 mg daily

Multivitamin daily

FH: Relationship Mortality Age Health Problems

Mother Deceased 54 Diabetes Mellitus II

Father Deceased 75 CAD

Daughter Deceased 20 MVA

Son Alive 45 None

ROS:

General: Denies weight loss, fatigue until the last 3 days, generally eats well

Skin: Denies birthmarks, scars, no previous rashes

HEENT: Denies dizziness, head trauma, vision trouble, does wear glasses, Had cataract surgery in L eye , denies swallowing problems, nasal congestion,

Neck: Denies lumps, pain, stiffness

Resp: Denies dyspnea or pain, cough, wheezing

Cardiac: Denies chest pain, or edema of extremities, Has had an irregular heart rhythm “for years”

Gastrointestinal: Denies nausea, vomiting, diarrhea or abdominal pain

Genitourinary: Denies hematuria, dysuria, or odor

Musculoskeletal: Denies back pains, Admits to knee pain with difficulty walking

Neurological: Denies seizures, limb weakness, headaches, loss of consciousness

Psychological: Denies depression/anxiety. No suicidal/homicidal ideations.

She likes to color and work on puzzles but sometimes “I loose pieces” that makes me angry.

PE: Vital Signs: Temp 98.6 HR: 84 RESP: 18 BP: 149/90

Constitutional: Thin, frail-looking, well-kempt 85 yo female in NAD (no acute distress)

HEENT: Normocephalic, atraumatic, with thinning grey hair. Eyes with small xanthoma R outer canthus, conjunctiva pale, white sclera, cloudy R cornea, L cornea normal size and color PERRL, EOM intact.Snellen 20/40 using both eyes with glasses

Ophthalmoscopic Exam: Optic Red reflex intact bilaterally. Optic Disc is round creamy yellow with blurry margins. Retinal vessels are bright red without exudate, edema, and wool spots. Macula is positive for foveal light reflex.

Otoscopic Exam: No ear discharge, TM grey and intact, with mild amount of cerumen, crisp cone of light, Whisper test 2/3 bilaterally

Nose: patent nasal airways, no exudates, turbinates pink without polyps

Mouth: Wearing Dentures, no lesions, palate rises symmetrically , tongue/uvula midline, pharynx unremarkable

Neck: Supple without lymphadenopathy, thyromegaly, or carotid bruits, Has Full ROM, No JVD

Heart: Irregular S1S2 w/o gallops, or rubs, Grade II/VI murmur heard at 4th ICS LBS, , PMI @ 5ICS MCL

Lungs: Clear to auscultation bilaterally with equal excursion and normal tactile fremitus

Abdomen: soft ,thin with little fat, no masses, no HJR, no hepatosplenomegaly, Hypoactive bowl sounds in 4 quads. Rectum: with brown stool, no masses with normal tone. Small external hemorrhoids or fissures. Stool guaiac: negative

Genitourinary: No palpable inguinal nodes, wearing incontinent pad with faint smell of urine. Perineum intact without discharge, edema or skin lesions. Pelvic Exam deferred

Peripheral Vascular: No edema or cyanosis, or clubbing with +2 palpable radial, popliteal, pedal pulses bilaterally

Musculoskeletal: FROM of all extremities, no joint swelling, pain in upper extremities. Bilateral knees with creaking with extension and mild tenderness with extension. Strength and sensation in upper/lower extremities are symmetrical

Neurological: CN 2- 12 grossly intact. Ambulates slowly without assistance

Psychological: Alert, pleasant but subdued. Cooperative and follows commands.Communicative with focused answers.

Previous labs found in local hospital lab records from 2 months prior:

WBC 4.6 Sodium 128 (L)

RBC 3.45 (L) Potassium 5.3

Hgb 10.13(L) Chloride 104

HCT 33.2 (L) Albumin 3.8 (L)

MCV 78.3 (L) Total protein 6.3 (L)

MCH 28.2 AlkPhos 100

MCHC 32.4 ALT 22

RDW 16.2 (H) AST 28

Platelets 221 LDH 134

Segs 66(H) T. Chol 252 (H)

Lymphocytes 21 (L) Calcium 8.4 (L)

Monocytes 8 FBS 130 (H)

Based on this information, what is your problem list?

What is the difference between delirium vs dementia?

What else is missing and you would need to know?

What additional diagnostic testing would you order?

What health promotion/maintenance measures would you consider?