Copeland Case 5 Consultation
Patient Name: Fanny Copeland
Patient ID: 115463
Date of Birth: 10/25/----
Age: 58
Sex: Female
Room Number: Hillcrest Memory Diagnostic Center
Consultant: Lyndon F.Talcott, MD Neurology
Requesting Physician: Stella Rose Dickinson, PhD Psychology
Date of Consult: 04/28/----
CHIEF COMPLAINT: Memory loss.
HISTORY: Ms. Copeland is a very pleasant 58-year-old white female who gives a history of several years of what she calls short-term memory problems. She has had no long-term deficits. No family history of dementia. Denies head injuries specifically the loss of consciousness although she did have a blow to the head four years ago. She has had no strokes, denies any current sensory or motor loss. She had a single seizure back about 30 years ago without recurrence. MRI scan done at that time was apparently negative.
PAST MEDICAL/SURGICAL HISTORY: Her past medical history is remarkable for a single seizure. Migraine x 1, some 12 years ago. DJD urinary bladder spasms. She has had a previous tonsillectomy, appendectomy, hysterectomy, bilateral salpingo-oophorectomy.
ALLERGIES: Has a reaction to tetracycline. But no true drug allergies.
MEDICATIONS: Estrodiol, Detrol, ibuprofen, vitamin E, and multivitamins.
PHYSICAL EXAMINATION: Revealed a pleasant but depressed appearing female who is over weight but in no acute distress. She wears a brace on her right wrist. Height is 5 feet 7 inches. Weight 252 pounds. Temperature 98°F. Pulse 80. Respiratory rate 20. Blood pressure 140/80. She has not carotid bruits or meningismus. Cranial nerves 2 through 12 are intact and detailed to include visual fields. Funduscopic exam and pupillary examination. Motor exam reveals 5 out of 5 strength in arms and legs without atrophy or vesiculation. Reflexes are trace over four. Sensory exam is negative and nonfocal.
(Continued)
CONSULTATION
Patient Name: Fanny Copeland
Patient ID: 115463
Date of Consult: 04/28/----
Page2
Cerebellar exam
Patient ID: 115463
Date of Birth: 10/25/----
Age: 58
Sex: Female
Room Number: Hillcrest Memory Diagnostic Center
Consultant: Lyndon F.Talcott, MD Neurology
Requesting Physician: Stella Rose Dickinson, PhD Psychology
Date of Consult: 04/28/----
CHIEF COMPLAINT: Memory loss.
HISTORY: Ms. Copeland is a very pleasant 58-year-old white female who gives a history of several years of what she calls short-term memory problems. She has had no long-term deficits. No family history of dementia. Denies head injuries specifically the loss of consciousness although she did have a blow to the head four years ago. She has had no strokes, denies any current sensory or motor loss. She had a single seizure back about 30 years ago without recurrence. MRI scan done at that time was apparently negative.
PAST MEDICAL/SURGICAL HISTORY: Her past medical history is remarkable for a single seizure. Migraine x 1, some 12 years ago. DJD urinary bladder spasms. She has had a previous tonsillectomy, appendectomy, hysterectomy, bilateral salpingo-oophorectomy.
ALLERGIES: Has a reaction to tetracycline. But no true drug allergies.
MEDICATIONS: Estrodiol, Detrol, ibuprofen, vitamin E, and multivitamins.
PHYSICAL EXAMINATION: Revealed a pleasant but depressed appearing female who is over weight but in no acute distress. She wears a brace on her right wrist. Height is 5 feet 7 inches. Weight 252 pounds. Temperature 98°F. Pulse 80. Respiratory rate 20. Blood pressure 140/80. She has not carotid bruits or meningismus. Cranial nerves 2 through 12 are intact and detailed to include visual fields. Funduscopic exam and pupillary examination. Motor exam reveals 5 out of 5 strength in arms and legs without atrophy or vesiculation. Reflexes are trace over four. Sensory exam is negative and nonfocal.
(Continued)
CONSULTATION
Patient Name: Fanny Copeland
Patient ID: 115463
Date of Consult: 04/28/----
Page2
Cerebellar exam