Assessment of Cognition and the Neurologic System
Patient Information:
Initials: J.S.
Age: 67
Sex: Male
Race: Caucasian
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CC (chief complaint): “Forgetfulness.”
HPI: Mr. J.S., a 67-year-old Caucasian male, presents with a chief complaint of forgetfulness. His daughter, Asia, expresses concern over his increasing memory lapses, like misplacing car keys and needing directions back home after driving to the store. The forgetfulness is affecting his daily life, prompting the family’s visit. No history of head trauma or recent illness is reported. Asia also notices occasional disorientation and difficulty recalling recent events. However, Mr. J.S. denies other cognitive symptoms, weakness, numbness, or vision changes.
Current Medications: The patient is taking Aspirin 81mg for cardiovascular health, Lisinopril 10mg for hypertension, Metformin 500mg for diabetes, and a daily Fish oil supplement (1000mg) for cardiovascular support.
Allergies: No known medication, food, and environmental allergies
PMHx: There is a history of hypertension diagnosed three years ago, managed with Lisinopril, and type 2 diabetes diagnosed one year ago, controlled with Metformin. No major surgeries, blood transfusions, or other significant illnesses have been reported.
Soc Hx: The patient is retired and previously worked as an accountant. He enjoys gardening and spending time with his family, including his wife, two adult children, and three grandchildren. Mr. J.S. has never smoked and does not take alcohol. He diligently uses seat belts while driving and has working smoke detectors in his house. He lives in a supportive environment with family nearby.
Fam Hx: The patient’s father had Alzheimer’s disease, his sister had hypertension, and his aunt had type 2 diabetes. There is no history of contagious illnesses. His mother passed away from heart failure, and his maternal grandfather had a history of stroke.
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ROS:
GENERAL: Denies any fever, chills, or unintentional weight loss. Reports fatigue and occasional difficulty sleeping.
HEENT:
Eyes: No visual changes, but experiences mild eye strain after prolonged reading.
Ears: No hearing loss or tinnitus reported.
Nose: No congestion or nasal discharge.
Throat: No sore throat or difficulty swallowing.
SKIN: No rashes, itching, or skin abnormalities observed.
CARDIOVASCULAR: Denies chest pain, palpitations, or edema in extremities.
RESPIRATORY: No cough, shortness of breath, or wheezing.
GASTROINTESTINAL: Reports occasional mild indigestion and no significant changes in bowel habits.
GENITOURINARY: No urinary frequency, urgency, or pain during urination. Denies any genital abnormalities or discharge.
NEUROLOGICAL: No headaches or seizures were reported.
MUSCULOSKELETAL: Mild, occasional joint stiffness but no significant joint pain or swelling.
HEMATOLOGIC: No history of bleeding disorders or abnormal bruising.
LYMPHATICS: No lymph node swelling or tenderness.
PSYCHIATRIC: No history of depression, anxiety, or other psychiatric disorders.
ENDOCRINOLOGIC: No heat or cold intolerance. Denies excessive thirst or hunger.
ALLERGIES: No known medication, food, or environmental allergies were reported.
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Physical exam:
GENERAL: The patient appears to be a well-nourished and well-groomed 67-year-old male. He is alert and oriented to person, place, and time. No acute distress was noted.
HEAD: Normocephalic, atraumatic. Hair distribution and scalp are within normal limits.
EENT:
Eyes: Pupils are equal, round, and reactive to light. Extraocular movements are intact. No conjunctival injection or discharge. No obvious cataracts or other abnormalities were observed.
Ears: Bilateral canals are clear with normal tympanic membranes. No signs of infection or cerumen impaction.
Nose: Nasal mucosa is pink and moist. No nasal septal deviation or masses.
Throat: The Oropharynx is clear, and the tonsils are non-enlarged.
SKIN: No notable rashes, lesions, or discoloration. Skin is warm and dry to the touch.
CARDIOVASCULAR: Heart rate regular, no murmurs, rubs, or gallops. Peripheral pulses are palpable and symmetrical.
RESPIRATORY: Lungs are clear to auscultation bilaterally. The respiratory rate is within normal limits.
GASTROINTESTINAL: Abdomen is soft, non-tender, and non-distended. Bowel sounds are present in all four quadrants.
GENITOURINARY: Not hematuria, increased frequency, or urgency
NEUROLOGICAL: Cranial nerves are intact. No focal motor deficits were observed. Strength and sensation are symmetrical.
MUSCULOSKELETAL: Mild tenderness was noted in some joints, but no obvious swelling or deformities were observed.
HEMATOLOGIC: No signs of petechiae or ecchymosis noted.
LYMPHATICS: No enlarged lymph nodes palpated.
PSYCHIATRIC: The patient appears cooperative, and no signs of anxiety or depression are evident during the examination.
ENDOCRINOLOGIC: No significant findings related to the endocrine system were observed.
Diagnostic results:
- Cognitive Assessment: Administering standardized cognitive tests, such as the Mini-Mental State Examination (MMSE) or Montreal Cognitive Assessment (MoCA), to assess the patient’s memory, attention, and other cognitive functions.
- Complete Blood Count (CBC): To check for signs of infection, anaemia, or other hematologic abnormalities (Ball et al., 2019).
- Basic Metabolic Panel (BMP): To assess kidney function, electrolyte levels, and glucose levels (Sullivan, 2019).
- Lipid Profile: To evaluate cholesterol levels and cardiovascular risk factors (Sullivan, 2019).
- Fasting Blood Glucose or Hemoglobin A1c: To evaluate the patient’s blood sugar levels and screen for diabetes (Ball et al., 2019).
- Brain Imaging: MRI or C.T. scan of the brain to rule out structural abnormalities, such as tumors or stroke, which could be contributing to cognitive impairment (Sullivan, 2019).
- Thyroid Function Tests: To assess thyroid hormone levels, thyroid dysfunction can sometimes cause cognitive issues (Ball et al., 2019).
- Vitamin B12 and Folate Levels: To check for deficiencies contributing to memory problems (Sullivan, 2019).
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Differential Diagnoses:
- Probable Alzheimer’s Disease (A.D.): ICD-10 Code: G30.9. The patient’s chief complaint of forgetfulness, cognitive impairment, difficulties with daily activities, and a family history of Alzheimer’s in the patient’s father indicates the possibility of A.D. (Scheltens et al., 2021).
- Mild Cognitive Impairment (MCI): ICD-10 Code: G31.84. The patient’s subjective memory complaints without significant functional impairment could suggest MCI, a precursor to A.D. (Cherry et al., 2021).
- Normal Age-Related Cognitive Decline: ICD-10 Code: R41.81. Given the patient’s age (67 years old), some degree of cognitive decline might be expected as part of normal aging, especially in the absence of significant functional limitations (Cherry et al., 2021).
- Vascular Dementia: ICD-10 Code: F01.5. The patient’s history of hypertension, possible cerebrovascular disease, and cognitive impairment raises the possibility of vascular dementia (Scheltens et al., 2021).
- Depressive Disorder with Cognitive Symptoms: ICD-10 Code: F32.9. Cognitive symptoms like forgetfulness, which the patient experiences alongside mood changes, may suggest depressive disorder with cognitive symptoms (Dumurgier & Tzourio, 2020).
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Cherry, K. E., Brigman, S., Burton-Chase, A. M., & Baudoin, K. H. (2021). Perceptions of forgetfulness in adulthood. The Journal of Genetic Psychology, 182(1), 31–46. https://doi.org/10.1080/00221325.2020.1840330
Dumurgier, J., & Tzourio, C. (2020). Epidemiology of neurological diseases in older adults. Revue neurologique, 176(9), 642-648. https://doi.org/10.1016/j.neurol.2020.01.356
Scheltens, P., De Strooper, B., Kivipelto, M., Holstege, H., Chételat, G., Teunissen, C. E., … & van der Flier, W. M. (2021). Alzheimer’s disease. The Lancet, 397(10284), 1577-1590. https://doi.org/10.1016/S0140-6736(20)32205-4
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
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