Case 5 History and Physical
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) problems. There is no history of TBI (traumatic brain injury) or LOC (Level of consciousness) but the patient reported that she had hit her head on the right side creating her TMJ problems. She denies ETOH (Ethanol) intake or smoking. Current medicines include: ibuprofen and Detrol. On admission to the MDC (Memory Diagnostic Center) the patients score on the MMSE was 3-D over 3-D and she was able to recall all three words. Clinical dementia rating was 1. Score on the geriatric depression scale was 12. For further information please refer to patients medical records. Ms. Copeland has a high school education with some college course work. She has worked for about 30-years as an editor. Currently she resides in her own home with her granddaughter with is sixteen. The patient’s granddaughter Jance, moved in about 3-years-ago and has had academic problems and reduced moderation. Ms. Copeland has tried counseling and the Date Counting Learning Center without much success secondary to Jance’s reduced communication and tendencies to sabotage own successes . Ms. Copeland is under considerable stress and does not know for sure if her problems with her memory have worsened. Ms. Copeland indicated that she has noticed memory problems
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) problems. There is no history of TBI (traumatic brain injury) or LOC (Level of consciousness) but the patient reported that she had hit her head on the right side creating her TMJ problems. She denies ETOH (Ethanol) intake or smoking. Current medicines include: ibuprofen and Detrol. On admission to the MDC (Memory Diagnostic Center) the patients score on the MMSE was 3-D over 3-D and she was able to recall all three words. Clinical dementia rating was 1. Score on the geriatric depression scale was 12. For further information please refer to patients medical records. Ms. Copeland has a high school education with some college course work. She has worked for about 30-years as an editor. Currently she resides in her own home with her granddaughter with is sixteen. The patient’s granddaughter Jance, moved in about 3-years-ago and has had academic problems and reduced moderation. Ms. Copeland has tried counseling and the Date Counting Learning Center without much success secondary to Jance’s reduced communication and tendencies to sabotage own successes . Ms. Copeland is under considerable stress and does not know for sure if her problems with her memory have worsened. Ms. Copeland indicated that she has noticed memory problems