Case 5 History and Physical Essay

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Pages: 7


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)
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Tested verbal fluency under time and pressure and naming to confrontation were unremarkable. Language comprehension was unremarkable for conversion and for simple instructions presented in oral written formats.

MEMORY: Recall of basic autobiographical information was unremarkable. Invent memory was unremarkable. Immediate for recall sentences was unremarkable. Delayed recall of two sentences was unremarkable. Immediate recall of paragraph length stories was a high average and did decline to the low average range after a thirty-minute delay. Immediate verbal recognition memory was unremarkable, five of five words and did not decline, five of five words after a brief delay. Immediate visual recognition memory was unremarkable, four of four designs and did not decline, four of four designs after a brief delay.

MOTOR PRACTICE: Basic motor function was unremarkable. Bi-manual motor programming was unremarkable. Buccofacial, limb gestural and limb manipulation apraxia were unremarkable.

SENSORY PERIPHERAL: Primary sensory functions were adequate for performance of all tasks. Auditory processing was unremarkable. Visual discrimination was unremarkable. Visual perceptual judgment was unremarkable. Visual motor integration draw to copy was