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Performance Overview for case Janet Riley The following table summarizes your performance on each section of the case, whether you completed thatsection or not. Time spent: Status: Submitted Case Section Status Your Score Time spent Performance Details History Done 100% 23min 43sec 57 questions asked, 41 correct, 0 missed relative to the case's list Physical exams Done 96% 18min 29sec 39 exams performed, 25 correct, 0 partially correct, 0 missed relative to the case's list Key findings organization Done 4min 33sec 13 findings listed; 16 listed by the case Problem statement Done 2min 0sec 96 words long; the case's was 64 words Differentials Done 100% 2min 57sec 9 items in the DDx, 9 correct, 0 missed relative to the case's list Differentials ranking Done 100% (lead/alt score) 100% (must not miss score) 0sec Tests Done 100% 3min 23sec 11 tests ordered, 11 correct, 0 missed relative to the case's list Diagnosis Done 100% 58sec Management plan Done 11sec 796 words long; the case's was 311 words
Exercises Done 100% (of scored items only) 1min 51sec 10 of 10 correct (of scored items only) Attempt: History Questions ( 41 correct)
- What is your name (patient)
- Where are you?( patient)
- What time is it? patient))
- What happened?( patient)
- How can I help you today (patient)
- Do you feel confused at times? (patient)
- Have you dropped many of your activities and interests? (patient)
- Do you have trouble with reasoning, planning or organizing? (patient)
- Have you noticed a decline in your thinking? (patient)
- Have you been depressed? (patient)
- Do you have a problem remembering things. (patient)
- How would you describe your mood? (patient)
- Do you sometimes have trouble remembering things or finding the right names or words? (patient)
- How can I help her today?(witness)
- Does she have any other symptoms or concerns we should discuss? (patient)
- Has she lost weight (witness)
- Does she have a problem with depression (witness)
- Has she lost interest in things that used to give her pleasure? If so how often does she feel this way (witness)
- Does she have trouble with reasoning, planning or organizing (witness)
- Has she noticed a decline in her thinking (witness)?
- Has she recently had any mood or personality changes? (witness)
- When did her confusion start (witness)?
- Does her confusion come and go? (witness)
- Is there any pattern to when her confusion occurs? (patient)
- Can she describe the nature of confusion or the types of memory loss (witness)
- What treatments has she had for her confusion? (witness)
- Neurological: reflexes deep tendon
- Neurological: reflexes plantar/babniski l5/s
- Neurological: sensory tests light touch, pain, position temperature, vibration
- Neurological: Mini-mental state exam
- Neurological: rapid alternating movements arms/hands
- Genitourinary: G/U female exam
- Musculoskeletal: inspect for muscle bulk and tone
- Musculoskeletal: test range of motion
- Musculoskeletal: test strength
- HEENT: Inspect mouth/pharynx
- HEENT: test hearing
- Neck: Inspect neck
- Neck: palpate neck
- HEENT test visual acuity
- Skin, hair nails: inspect skin overall
- Abdomen: palpate abdomen
- Heart: palpate for PMI
- Extremities; visual inspection of extremities FINDINGS: correct Ranking
- Impaired memory - MSAP
- Personality changes-related
- Increase in level of confusion- related
- Poor concentration levels-related
- Impaired judgement-related
- Paranoid ideations-related
- Anhedonia-related
- Impaired performance ADLs-related
- Oriented .#2 only - related
- Geriatric depressive possible symptomatology-unknown
- Weight loss-unknown
- Coronary artery disease-unknown
- Hypertension -unknown
- Hyperlipidemia-unknown
- History of head trauma-unknown
- Hearing loss-unknown Case: Key Findings Feedback The medical problem list you have compiled should be a list that includes everything that is out of the ordinary about this patient, even when it is not a "problem" in the true sense of the word. In this 79-year-old female, the most significant active problem (MSAP) is impaired memory and related behavioral changes. Look through the list of problems identified. What medical conditions frequently found in the geriatric population has this list: Personality change
- Confusion. Poor concentration
- Impaired judgment Paranoid ideation Disengagement/loss of interest in valued activities
- Decline in performance of ADLS . Unintended weight loss Some problems could be grouped as potential risk factors for behavioral changes: Hypertension Hyperlipidemia History of head trauma Newly widowed status (despite low but somewhat ambiguous geriatric depression score) Next look for specific physical findings identified during your examination of the patient. Hearing loss is a common, non-specific finding but the loss of orientation to time is significant. In whatmedical conditions is this a prominent finding? In developing your differential diagnosis, keep in mind that there not only may be cross-over findings between various hypotheses, but that some conditions that may explain Ms. Riley's presentation may actually coexist as mixed etiologies, or as comorbidities. Also ▷remember that the geriatric population frequently does not exhibit the same degree of physical findings for some medical conditions, thus more
has hypertension and coronary artery disease. Ann reports that she has noticed changes in Mrs. Riley's personality; inability to perform her activities of daily living, and lack of interest in previous activities and friends. Mrs. Riley is difficult to assess, is disoriented (Alert to person and place), and denies the need to visit the doctor. Her hygiene is deteriorating, and has obvious malodorous body odor DDX RANKING
- Dementia, Alzheimer’s
- Dementia frontotemporal
- Dementia, lewy body
- Dementia; vascular
- Dementia, mixed,
- Occult infection
- Hypothyroidism
- Anemia vit B 12 def
- Medication induced delirium Tests (11)
- Brain MRI
- CBC
- CMP
- FOLATE SERUM
- Free thyroxine FT
- HOMOCYSTEINE
- HIV antibody
- Rapid plasma regain
- TSH
- URINALYSIS
- VIT B
Management Plan by case Janet Riley Diagnostic tests The diagnostic tests for Alzheimer's disease include a physical exam, a review of the patient's medical history, laboratory tests, and neuroimaging tests. The physical exam can help rule out other conditions that can cause dementia-like symptoms. The medical history can help identify risk factors for Alzheimer's disease, such as family history and head injuries. Laboratory tests can help rule out other conditions that can cause dementia-like symptoms, such as thyroid problems and vitamin deficiencies. Neuroimaging tests, such as CT scans and MRI scans, can help show changes in the brain that are characteristic of Alzheimer's disease (Kabir et al.,2020). Medications with Prescriptions The treatment plan for Alzheimer's disease typically includes medications to help improve memory, support cognitive function, and manage behavioral problems. There are three main types of medications used to treat Alzheimer's disease: cholinesterase inhibitors, memantine, and combination therapy (Dwivedi et al., 2019). Cholinesterase inhibitors are medications that work by boosting levels of a chemical called acetylcholine in the brain. This chemical is important for memory and other cognitive functions. Common cholinesterase inhibitors used to treat Alzheimer's disease include donepezil (brand name Aricept), rivastigmine (brand name Exelon), and galantamine (brand name Razadyne). Memantine is a medication that works by blocking the activity of a neurotransmitter called glutamate. Too much activity of this neurotransmitter has been linked to the development of Alzheimer's disease. Memantine is used to treat moderate to severe Alzheimer's disease. Combination therapy is the use of two or more medications to treat Alzheimer's disease. One common combination therapy used to treat Alzheimer's disease is a combination of donepezil and memantine (Thakur et al., 2018). The usual starting dose of donepezil is 5 mg once daily. The dose may be increased to 10 mg once daily after 4 to 6 weeks if needed. The usual starting dose of rivastigmine is 4.6 mg once daily. The dose may be increased by 4.6 mg every 2 weeks as needed. The maximum dose is 23.2 mg per day. The usual starting dose of galantamine is 4 mg twice daily. The dose may be increased by 4 mg every 2 weeks as
Electronic Health Record by on case Janet Riley History of Present Illness Category Data Reasonfor Encounter ""confusion and memory loss"- Family member Reports History of present illness 79 year old female with Past medical history significant of hypertension, HLD, CAD, and insomnia brought in today by her daughter who states patient has been experiencing increasing memory loss and confusion. The informant presents helps in presenting the detailed information for this client Past Medical History Category Data Past Medical History Hypertension at age 55 Coronary artery disease: status/post stent placement in left main coronary artery: dx at age 65. Hypercholesterolemia at age 55 Occasional insomnia Bilateral sensorineural hearing loss (with hearing aids) and with contact lenses Hospitalizations / Surgeries Childhood illnesses: unremarkable.G2P2, NSVD ,no complications. No other hospitalizations or surgeries Medications Category Data Medications Atorvastatin 40 mg/d Lisinopril 20 mg/d Atenolol 50 mg/d Hydrochlorothiazide 12.5 mg/d Aspirin 81 mg/d Zolpidem 5 mg/d nightly as
needed for insomnia Allergies Category Data Allergies No known food, drug or environmental allergies. Preventive Health Category Data Preventive health Age-appropriate screening: has undergone colonoscopy, mammograms, and bonedensity evaluations Safety measures: lives in a downtown Chicago apartment with smoke alarms: wears seatbelt; does not own a gun Environmental and occupational exposures: none known Exercise: enjoys long walks throughout neighborhood and along lake shore; previously and avid tennis player FamilyHistory Category Data Family History Mother: deceased at age 83; suspected congestive heart failure Father: deceased at age 72; prostate cancer Brother: deceased at age 59; bladder cancer Adult children (2): healthy; as are grandchildren Social History Category Data Social History Worked as an elementary school teacher for 35 years; retired 9 years ago Marital status: Husband passed away 2 years ago Family support: Two grown children and two grandchildren Alcohol and drugs: occasional at family gatherings Diet: dairy intolerance Review of Systems Category Data General The patient is an elderly woman who presents with memory problems. She reports difficulty recalling recent events and names of people she knows. She also has trouble with spatial orientation and is often disoriented as to where she is. Integumentary / Breast The patient reports no rashes, itching, or skin problems. HEENT / Neck The patient denies headaches, dizziness, or vertigo.
s1 s2 heart on auscultation Chest / Respiratory chest symmetrical. Anteroposterior diameter is normal. Excursion with respiration is symmetrical; no abnormal retractions no distention, scars or amss4s or rashes Resonant lung fields. No hyper-resonance noted Abdomen Flat abdomen, symmetric with no evidence of scars deformities or lesions On percussion, no shifting dullness or tympany. Genitourinary / Rectal odor of urine moderate; seen in patients undergarments Bimanual exam done- 1 finger. no palpable adnexal mass Musculoskeletal / Osteopathic Structural Examination Muscle bulk reduced for age and weight No spine deformity Knees: slight crepitance Neurologic Mini MSE done; 19/30. Oriented to person and place. Misses year, week, day, and date. Poor ability to tolerate the test conditions and request for cooperation. Response to multiple questions with "i don't know" The gait and stance is slightly stooped Psychiatric Affect: apprehensive Appears anxious Abnormal stability Distorted mood and affect, overall Memory impaired Insight absent Lymphatic no lymphadenopathy Attempt:
