Chief Complaint
“I can’t seem to balance my checkbook anymore, and I got in the car the other day to drive to the grocery store but it was like I forgot how to drive. My daughter also thinks that I become easily agitated lately.”
Source: http://www.alz.org/alzheimers_disease_1973.asp
History of Present Illness
Mrs. Heston is a 74 YO white female who visited her PCP four months ago complaining of slight memory impairment, cognitive impairment relating to problem-solving, and dramatic mood swings. Her PCP referred her to a neurologist. Since first visiting the neurologist, Mrs. Heston has become unable to complete simple tasks, such as cooking her favorite meal. Her daughter also notices that her mother sometimes becomes confused in the afternoon, believing she is working in her former position as a school secretary instead of at home.
Past Medical History
- Wisdom teeth extraction, age 22 years
- Obstetric history – 2 term infants, 1 premature infant, 1 stillborn, 3 living children
- GERD, age 60 years
- Breast cancer resulting in double mastectomy, age 62 years
- Hypertension, age 70 years
- Hyperlipidemia, age 70 years
Pertinent Family History
- Both grandparents on mother’s side diagnosed with diabetes mellitus, type 2 in middle age
- Mother died from pancreatic cancer at age 45
- Father died from MI due to coronary heart disease at age 67
- All offspring are alive and well
- No familial history of dementia or Alzheimer’s Disease (AD)
Pertinent Social History
- Graduated high school and did not pursue a higher education degree
- Worked for twenty years as an elementary school secretary after her children were in school
- Widowed with three adult children
- Has never smoked and rarely drinks alcohol
- Loves to cook, travel, and read mystery novels
Allergies
- Strawberries (rash and anaphylaxis as a child)
- Latex (rash, age 18 years)
Medications
- Benazepril hydrochloride (Lotensin) 40 mg po QD
- Ranitidine hydrochloride (Zantac) 150 mg po BID
- Rosuvastatin (Crestor) 10 mg po QD
Focused Physical Exam
Mental Status
- Mini-Mental State Exam (MMSE) score of 19 (out of maximum 30), indicating moderate dementia (Mini Mental State Examination)
- Dementia Mood Assessment Scale (DMAS) score of 98 (out of possible 144), indicating moderate dementia (Dementia Mood Assessment Scale)
- Rowland Universal Dementia Assessment Scale (RUDAS) score of 22 (out of maximum 30), indicating possible cognitive impairment (Rowland Universal Dementia Assessment Scale)
- Alzheimer’s Disease Assessment Scale (ADAS) score of 21 correct responses (out of maximum 50), indicating moderate dementia (Alzheimer’s Disease Assessment Scale)
Neurological
- All cranial nerves intact
- Slight delay in motor response
- Deep tendon reflexes intact
- Slightly impaired coordination
- Slightly impaired gait related to age-related changes to musculoskeletal system