- Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.
With regard to the case study you were assigned:
- Review this week’s Learning Resources, and consider the insights they provide about the case study.
- Consider what history would be necessary to collect from the patient in the case study you were assigned.
- Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
- Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
THE CASE STUDY ASSIGNMENT
Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.
Case Study 2: Forgetfulness
Asia brings her 67-year-old father into the office stating he is very forgetful. He has lost his car keys several times. She also states he has driven to the store and called her asking for directions to get back home.
Episodic/Focused SOAP Note:
Subjective: Asia brings her 67-year-old father into the office, expressing concerns about his increased forgetfulness. According to Asia, he has been losing his car keys on multiple occasions, and there have been instances where he drove to the store but couldn’t remember the route to return home.
History: To better understand the patient’s condition, the following history would be necessary to collect:
- Medical History: Gather information about any pre-existing medical conditions, including neurological disorders, cardiovascular diseases, diabetes, or any other relevant medical history.
- Cognitive History: Inquire about any previous episodes of memory loss or cognitive decline, changes in behavior or personality, and if there is any family history of dementia or Alzheimer’s disease.
- Medication Review: Obtain a detailed list of the medications the patient is currently taking, including over-the-counter drugs and supplements, as some medications may cause cognitive side effects.
- Lifestyle and Habits: Ask about the patient’s lifestyle, including diet, exercise, alcohol consumption, and smoking habits, as these factors can impact cognitive health.
- Psychosocial History: Explore the patient’s social support system and any recent life events or stressors that may contribute to his forgetfulness.
Physical Examination and Diagnostic Tests: Based on the patient’s symptoms, the following physical exams and diagnostic tests would be appropriate:
- Mini-Mental State Examination (MMSE): A standardized cognitive screening tool to assess the patient’s cognitive function and identify any signs of cognitive impairment.
- Neurological Examination: A thorough neurological assessment to evaluate the patient’s reflexes, sensory responses, coordination, and other neurological functions.
- Blood Tests: Conduct routine blood tests to check for conditions like vitamin deficiencies, thyroid dysfunction, or metabolic disorders that could contribute to memory problems.
- Brain Imaging: Consider brain imaging, such as MRI or CT scans, to rule out structural abnormalities, tumors, or other brain-related issues.
- Depression and Anxiety Screening: Assess the patient for symptoms of depression or anxiety, as these conditions can also manifest as cognitive problems.
Possible Conditions for Differential Diagnosis:
- Alzheimer’s Disease: Characterized by progressive cognitive decline, memory loss, and disorientation, Alzheimer’s disease is a common consideration in cases of forgetfulness, especially in older adults.
- Vascular Dementia: This type of dementia is caused by reduced blood flow to the brain, resulting in cognitive impairments and memory difficulties.
- Mild Cognitive Impairment (MCI): MCI is a transitional stage between normal aging and dementia, where individuals experience mild memory problems beyond what is expected for their age.
- Depression: Mood disorders, like depression, can cause cognitive symptoms, including forgetfulness and difficulty concentrating.
- Medication Side Effects: Some medications, particularly those used to manage certain medical conditions, can lead to memory issues as a side effect.
Justification:
The differential diagnoses listed above are considered based on the patient’s age, presenting symptoms, and common conditions associated with forgetfulness. Further evaluation through physical exams and diagnostic tests will help narrow down the actual cause and guide appropriate treatment strategies.