BlogNewsExtract a soap note the data

My memories from childhood college and raising my children still same crystal player. Just to review. How old are you now? I turned 70 last fall. has life been hard for you since your husband passed away? Was it three years ago? We were always close and yes, it’s been quite an adjustment. I’m thankful my children and grandchildren are close by. How would you describe your spirits right now? Do you mean am I depressed? No. Not really. I’m sad sometimes when I think about the past and I feel lonely. Most of the time. I look forward to each new day and I’m volunteering quite a bit and I exercise much more than I used to. Have you had any trouble balancing your checkbook or keeping track of your bank account? So far? That’s okay. No overdrawn checks yet. What about walking or driving? Have you had any trouble finding your way? No, I’ve never really been lost. How’s your health in general? I see you’ve been treated for high blood pressure. My health has been good except for that. I take the blood pressure medicine and my blood pressure has been fine. I have some trouble sleeping. So I take some over the counter pills when I need to. Can you list all the pills you’ve been taking right now? Just hydro chordify aside and Ben Abril. Anything else? Do you take vitamins or herbal medication? Now just those two drugs? What about your sleeping? Have you been drowsy at all during the day? If I take the Benadryl I’m fine. And I never really slept during the day. Do you drink alcohol? Many older patients drink when they’re alone. I have a glass of wine with dinner three or four times a week. But drinking has never been a problem. For me. How about any changes in your weight or recent infections? No, but I’m committed to exercise so I stay in shape and I refuse to let myself go. That’s great. And exercise is so important for your strength and balance. Has anyone in your family had memory problems or dementia? My mother said that two of my grandparents were senile late in life but that’s all I know about. Is there anything we’ve missed that you want to add? No, that’s everything. But I hope I’m okay. I want to stay independent and do whatever I can to take care of this. Just to summarize, in the past few months, you and your family have noticed that you are more forgetful with names and recalling words on our next visit. You should ask one of your family members to come in with you. That will help us better understand your family’s concerns. For now, let’s do your physical examination. And some basic tests and we’ll talk more with the patient’s health history in mind, and after good hand hygiene, you are ready for the physical examination. Your blood pressure is 135 over 85 which is good and your heart rate and temperature are normal. What areas of physical examination are important for this patient? Press pause and list your answers. resume when you’re ready to receive feedback. Vital signs 10 minute geriatric screener, cardiovascular examination, thorax and lung examination abdominal examination neurologic examination with focus on mental status, especially the Montreal cognitive assessment test, cranial nerves, motor and sensory systems reflexes. First, I’d like to ask you a series of screening questions about your daily level of function. We call this the geriatric screener. The 10 minute geriatric screener is a convenient tool to have at hand when assessing all older adults. Note the eight components vision, hearing, leg mobility urinary incontinence, nutrition, weight loss, memory, depression, physical disability, test the patient’s vision, read this rule of numbers 374258 test the patient’s hearing 13279 Now I’m going to ask you to do the get up and go test when I tell you see stand up from the chair, walk to the mark on the floor. Turn around. Come back and sit down. Ready? Go. Alright, next, I’m going to examine your lungs, heart and abdomen. I want to make sure you don’t have any Brewery’s or rushing sounds in the arteries. In your neck. I’ll listen to the arteries in your abdomen for sound as well. The mental status examination is a key element in assessing mental function and memory to complete examination tests, appearance and behavior, speech and language, mood, thoughts and perceptions, cognition, including memory, attention, information and vocabulary calculations, abstract thinking and constructional ability. There are special screening tests for dementia, which are shorter and easier to use during a general office assessment and well validated. geriatricians now commonly use the Montreal cognitive assessment. scores less than 22 are consistent with dementia now draw a line in order for each number to each letter without taking your pin off of the paper. The Montreal cognitive assessment includes a trail making test, a clock drawing test, a word finding test and brief five item tests for memory, attention, language, and orientation. All right, now I’m going to read a list of five words. You listen to them and then repeat them. In five minutes, I will ask you to tell me these words again. Ready? Rose? Share. Velvet church, Daisy rose chair velvet church Daisy, Mrs. Wilson, please subtract seven from 193 and subtract seven from that. 86 Keep going 7974 68 rows share church I Can you recall three out of the five items after five minutes unless two of the subtractions so your score on the Montreal cognitive assessment is 26. This means you may have some early memory loss, but it’s mild. The mini cog is another validated screening tool. The mini cog tests three item recall and clock drive. After assessing mental status, carefully examined the nervous system, including cranial nerves, motor and sensory systems, and reflexes, comparing the left and right sides. Start your neurological examination and check what we call the 12 cranial nerves which supply important structures in your face and neck that affect vision, hearing and speech. Examine the 12 cranial nerves. One olfactory two optic three ocular motor for trochlear five trigeminal, six abducens seven, facial, eight Vestibulocochlear nine glossopharyngeal 10 Vegas 11 accessory 12 hypoglossal. All 12 cranial nerves with first motor and sensory function and reflexes, including the plantar reflex, going to check the strength of some of your muscles sensation and test muscle strength comparing the left and right sides to test the biceps patellar reflexes seem pretty good. Now I’m going to check the reflex on the bottom of your feet which we call the plantar reflex. This can feel your plantar reflexes are normal is that sharp stead about the same same. This Wilson. Please walk across the room turn around and walk back good. Your neurological examination except for the memory and subtraction changes on the Montreal cognitive assessments for this normal. Let’s review some of the details of this examination. In this 70 year old retired teacher and widow, what are your three diagnostic considerations in order of priority? Press pause and list your answers resume when you are ready to receive feedback. Memory loss is a common concern among older patients. The challenge is to distinguish the benign forgetfulness of aging from mild cognitive impairment, the several types of dementia and depression and to assess any adverse effects from medication newer polypharmacy. Dementia is an acquired cognitive condition that is characterized by a decline in at least two cognitive domains eg loss of memory, attention, language or visual spatial or executive functioning that is severe enough to affect social or occupational functioning the predominant form is Alzheimer disease, which affects 11% of Americans older than 65. onset is usually gradual, and often goes unrecognized.Extract a soap note the data Key initial features include the following persistent forgetfulness loss of short term memory, difficulty with word finding. Progression is indicated by problems with complex executive functions such as calculations, visual spatial impairment apraxia when dressing or using tools, getting lost social empathy, and disruptions of the day night’s sleep cycle. The spectrum of cognitive decline includes age related cognitive decline, mild cognitive impairment, Alzheimer disease, other dementias. age related cognitive decline is characterized by mild forgetfulness, difficulty remembering names and mildly reduced concentration. Episodes are sporadic and do not affect activities of daily living. In mild cognitive impairment, daily function is preserved but there is cognitive decline in one or more cognitive domains each year 10% to 15% of these patients progress to Alzheimer disease. Alzheimer disease is one of several dementia it’s these include Lewy Body disease, vascular dementia, and Frontotemporal dementia. Lewy Body disease affects 15% to 25% of patients with dementia, making it the second most common cause of dementia. clues are signs of Parkinsonism visual hallucinations, delusions, and gait disorder. This healthy 70 year old retired teacher is on the spectrum of cognitive decline. Her symptoms normal neurologic examination and Montreal cognitive assessment score are most consistent with mild cognitive impairment. Regular follow up with family members present will be important optimization of hearing vision, vascular risk factors and family engagement and social supports should be encouraged. depression affects 3% to 7% of community dwelling older adults and disease often undiagnosed. Presentation in older adults is often atypical, often in the form of somatic symptoms.

Extract a soap note the dataLook for delayed verbal responses and psychomotor slowing the prevalence of depression is higher in patients who are isolated bereaved and have multiple medical problems, especially chronic pain, Parkinson disease, cancer and alcohol abuse. Screening is straightforward to screening questions have a sensitivity as high as 100% and specificity up to 77%. These questions are during the past two weeks, have you felt down depressed or hopeless? And during the past two weeks, have you felt a little interest or pleasure in doing things? This patient has a positive effect and denies feeling depressed. She also lacks evidence of delirium. Another common contributor to changes in mental status, often arising from infection. Delirium is an acute confusional state with fluctuating attention, concentration, and orientation. Older Americans who use prescribed medications at the highest rates are highly subject to polypharmacy. among older adults 90% take at least one medication a day and almost 50% Take five or more medications daily. This accounts for more than half of adverse drug reactions that lead to hospitalization. The beers criteria provide widely used guidelines for drugs that are contraindicated in older adults. These drugs include diphenhydramine, which this patient is taking. Although occasional use of diphenhydramine is not likely to cause memory changes in this patient.

Extract a soap note the data, A careful sleep history is warranted and diphenhydramine should be discontinued. Over the counter pm products should be avoided. List the three next steps in your diagnostic workup. Press pause and list your answers. resume when you are ready to receive feedback. Neuro psychological testing entails formal testing of multiple cognitive domains.Extract a soap note the data

These include attention, orientation, executive function, verbal memory, spatial memory language, and calculations. mental flexibility conceptualization. In general, neuropsychological testing is reserved for more advanced stages of memory loss, so it can be deferred in this patient. A diagnosis of dementia requires evidence of cognitive decline, so input from family members and future visits will be essential.Extract a soap note the data.

If cognitive function is intact, then clinical causes of memory loss other than dementia should be pursued. Laboratory serologic tests the diagnosis of dementia rests on demonstrating the progression of cognitive change and neurologic findings over time. Reversible causes of dementia are rare, so serologic tests are of uncertain value. The following laboratory tests are recommended although the supporting evidence is limited, vitamin B 12 thyroid stimulating hormone, calcium, complete blood count, sedimentation rate, venereal disease research laboratory test, risk of Alzheimer disease increases significantly with positive apolipoprotein E for genotyping. But there are many patients with Alzheimer disease who do not have this gene. biologic markers such as amyloid beta and tau proteins are under study head CT or MRI. The use of neuroimaging varies by clinical setting and clinical guidelines are not uniform. In primary care and geriatric practices. Patients can be followed over several visits, whereas neurologists may see patients only once. neuroimaging is helpful for patients with atypical presentations. acute change in mental status, or in need of immediate reassurance. head CT and MRI can demonstrate diffuse brain atrophy and ventricular enlargement typical of Alzheimer disease. neuro imaging can also exclude vascular disease, subdural hematoma, and mass lesions on MRI, diffuse white matter lesions are suspicious or Alzheimer disease. In this patient, however, neuro imaging probably can be deferred until there is more evidence of cognitive decline. In summary, this 70 year old retired teacher reports recent problems with memory. She noticed loss of names, dates, and sometimes names of objects. doing crossword puzzles takes more time, and her family has noticed that she sometimes seems confused. She is in good health with the exception of hypertension, for which she takes hydrochloride thigh aside as prescribed. The patient exercises regularly and has moderate alcohol intake. She also takes diphenhydramine for insomnia.

Extract a soap note the data:However, this medication has adverse effects and is contrary indicated in older adults according to the beers criteria, and should be discontinued on physical examination. her vital signs or normal vision, hearing, leg mobility and get up and go testing on the 10 Minute geriatric screener are normal. She has a score of 26 on the Montreal cognitive assessment, her remaining neurologic function is intact with no evidence of focal findings. Diagnoses include dementia, depression, medication side effects. Possible diagnostic studies include neuro psychologic testing laboratory serologic tests, head CT or MRI