lOMoAR cPSD|44886145
SOPHIA KING I HUMAN CASE STUDY WEEK 6
NR601 79 YEARS OLD REASON FOR
ENCOUNTER:CONFUSION AND MEMORY LOSS
EXPERT REVIEW LATEST 2024-2025 .
Sophia King,
79y,
Caucasian female, 5’7”,
110lb c/o
REASON FOR ENCOUNTER :
confusion and memory loss
Location :
reported by family member that started last year; a& o x2, 37.2c, 68,
regular/normal, L 142/86/R 142/86, elevated/normal, 14, unlabored/regular,
97%
KEY FINDINGS:
,Stopped paying bills, cleaning house, basic personal hygiene, remembering names,
decrease in ac琀椀vi琀椀es/interests, weight loss, angry outbursts-6mths,
paranoia-someone stealing from her
Irritable: gradual over last year, every琀椀me daughter sees her, be琀琀er when
not talking about her problems,
Confusion: started 3 yrs ago, progressively go琀琀en worse last few months
yearmixes up words, le昀琀 bath water running, le昀琀 car running, passed exit
2x/week, repea琀椀ng her stu昀昀, nothing makes be琀琀er or worse, more
angry with help, some days worse than others; basic judgement, safety, worse late
a昀琀ernoonnigh琀me
Poor memory: more agitates, less focused, pre琀琀y advanced, can’t remember
where she puts things progressed last 6mths
Aloof/distant:
Mood changes: anxiety, paranoia
Change in ability to accomplish task
Di昀케culty with ADLstrou
Di昀케culty with housework/grocery shopping
Trouble driving?
Dropped many ac琀椀vi琀椀es/interests
HPI: (OLDCARTS)
Tell me how that makes you feel
How does this a昀昀ect your life
What sx most distressing for you
PMH: HTN with CAD – stent placement in le昀琀 main coronary artery,
hypercholesterolemia, insomnia, bilateral sensorineural hearing loss (with hearing
aids), G2P2 NSVD
,Childhood illnesses: unremarkable;
Immuniza琀椀ons: had 昀氀u shot last year, Prevnar 13 given.
Family hx:
• Mother – deceased 83y, CHF
• Father – deceased 72y, prostate cancer
• Brother – deceased 59y, bladder cancer
• Adult children (2) - healthy
Social Hx: re琀椀red elementary teacher, Allergies: NKDA meds: Atorvasta琀椀
n 40mg, lisinopril 20mg, atenolol 50, HCTZ 12.5, ASA 81mg, Zolpidem 5mg at
night OTC drugs: occasional alcohol at family gatherings
Diet: dairy intolerant.
Living situa琀椀on:
Death of partner? Husband passed away 3 yrs ago, has 2 grown children and 2
grandchildlren.
Loss of job/re琀椀red?
Problem Statement: relevant 昀椀ndings, physical 昀椀ndings, key 昀椀ndings
(150 wds)
Di昀昀 Dgs: (Lead vs. alternate; MNM)
Tests: (rule in vs rule out)
Mgmt Plan:
Pharm therapies
Suppor琀椀ve
therapies Pt educa琀
椀on f/u; red 昀氀ag
, Assessment
Skin: unkempt, warm, dry, excessive body odor, no pallor/jaundice, rashes, lesions,
bruising, scabbing
Nails: without ridiging, pi琀ng, peeling, capillary re昀椀ll less than 3s.
Hair: thickness/distribu琀椀on typical
Head: no visible scars, edema, masses, lumps, rashes, non-tender, normocephalic,
atrauma琀椀c, symmetric facial features, non-tender temporal arteries, non-
tender front/maxillary sinuses.
HEENT:
Eyes: no ptosis, erythema, swelling, pink conjunc琀椀vae, no discharge, anicteric
sclerae, wearing correc琀椀ve lneses, pt wouldn’t cooperate with eye exam, no
nystagmus with H test. PERRLA
Ears: no trauma/deformity to external structures, no discharge. Auditory canal
without erythema or cerumen, TM translucent, noninjected with pinkish-gray, no
scarring or discharge. Hearing aids in place with normal hearing on exam.
Nose: no discharge/polyps, no edema, non-tender frontal/maxillary sinuses.
Mouth: no hoarseness, clear mucosa, tonsils without exudate, pink tongue without
swelling/ulcera琀椀ons. Normal gag re昀氀ex. Fair den琀椀琀椀on for age, no
tenderness, or signs of infec琀椀on. No unusual odor
Neck: no scars, deformi琀椀es, midline trachea, thyroid 昀椀rm, no nodules,
thyroid moves with swallowing, JVP less than 3cm above sternum. No caro琀椀d
bruits.
Lymph: no enlarged/tender lymphs in cervical, supraclavicular, axillary, or inguinal
chains.
Resp: Normal AP diameter, symmetrical, unlabored breathing. No scars, deformi琀
椀es, no tenderness, masses, heaves, thrills, or crepitus. Anterior lung 昀椀elds are
resonant with dullness over heart and liver.
Cardaic: PMI 2cm beyond MCL. Normal ABI 1.0-1,4
