Obviously, identifying details have all been changed. This is the sort of thing I wish I could write. I might, actually, as I’m increasingly sure that nobody at work reads my notes anyway.
Date of Visit: @[email protected]
Referring Physician: @[email protected]
Reason for Referral/ Chief Complaint: This is a 78yo female w/ PMH including HTN, CKD 2, multifocal OA, R.hip replacement (circ 2015) who follows up for further evaluation of subjective memory issues as reported to PCP.
She reports that since ~11/2019, she has been having some subjective difficulty w/ short term memory. Specifically, she's noted issues w/ remembering people's names. Not the names of people she's close with, mind you – she can and will name all of her children, step-children, and (step-)grandchildren, whether you want her to or not. However, she recently moved into an ALF and she's organizing both the Christmas decorations for the entire facility, as well as the upcoming Christmas party (which I'm told is "actually being referred to as a 'Holiday Party,' but there are pinecones w/ glitter and laughing Santas so you tell me"). This has required her to assemble multiple spreadsheets and a big bulletin board for group assignments. Within the context of this Yuletide Blitzkrieg, she's found it hard to immediately recall the Christian names of the other 160 occupants of her ALF (that she's lived in for <6 months). Of note, she's quick to reassure me that she does remember their names a few minutes later, as well as whether or not they have a dog. She sees my expression and goes on to explain – with more pity than I’d prefer – that "doggies also need a Christmas," and have been accounted for in her spreadsheet.
Of note, she likes to keep up w/ current events and subscribes to a few journals. She's a retired college professor w/ a PhD in mathematics.
Past family & social history: The following portions of the patient's history were reviewed and updated as appropriate: allergies, current medications, past family history, past medical history, past social history, past surgical history and problem list.
HTN, CKD 2, multifocal OA
R.hip ORIF, 7/2015
Not having desk items organized, color coded, and at 90 degree angles to one another, I'm guessing.
Current medications Asa 81, Norvasc
Social Hx/Family Hx -Tried cigarettes as a teenager, found them disgusting.
-Drinks <1glass wine per wk, but thinks Michael Buble is "so talented, and handsome as the day is long."
-Tells me that her mother “also liked to have a place for everything and everything in it's place."
-Otherwise, family/social history reviewed and are not pertinent to presenting problem
Constitutional: Was clicking her tongue at something she’d just read in Architectural Digest on her ipad when I walked in, if that tells you anything.
Eyes: No pain, redness or visual changes.
Ears, Nose, Mouth: No oral or nasal ulcers.
Cardiovascular: No chest pain, irregular heart beat, or dizziness.
Respiratory: No shortness of breath, cough, pleuritic pain, or dyspnea on exertion.
Gastrointestinal: No nausea, diarrhea, constipation, abdominal pain, reflux, or dysphagia.
Musculoskeletal: No joint pain or swelling, ambulates without assistive devices.
Skin: No new rash or lesions.
Neurological: See HPI.
Psychiatric: No vegetative symptoms.
Endocrine: No heat or cold intolerance, no polyuria or polydipsia.
Temp: 30.2 C
General/Constitutional: well developed, normal body habitus. Spritely. Well dressed, but unfortunately wearing Xmas sweater w/ sewn-on red & green bells, distributed in such a way as to suggest nipple piercings.
Eyes: no conjunctival injection, no proptosis. Zest for Life and Inner Fire present bilaterally.
ENMT: normal, oropharynx clear
Respiratory: Unlabored breathing, comfortable on room air
CV: regular rate and rhythm, no peripheral edema
Psychiatric: alert and oriented with normal affect Musculoskeletal: normal bulk, full ROM
Mental status: Awake, alert, oriented to self, date, place. Follows commands. No neglect. Certainly no aphasia present.
CN: PERRL. VFF on confrontation. EOMI. Facial sensation intact to touch. Face symmetric. Hearing intact to voice. Palate/uvula midline. Tongue midline.
Motor: Normal tone. 5/5 strength in all extremities. No involuntary movements, but talks w/ her hands a lot.
Sensory: Intact to light touch and temperature. Arguably too sensitive to vibratory sense – distal exam prompts her to actually guess that I'm using a 128hz tuning fork
Coordination: No dysmetria/ataxia on FTN bilaterally.
Reflexes: 1-2+, symmetric in all extremities. Toes downgoing bilaterally.
Assessment/Plan: This is a 78yo female w/ PMH including HTN, CKD 2, multifocal OA, R.hip replacement (circ 2015) who follows up for further evaluation of subjective memory issues as reported to PCP.
Given the history above, one has to assume that she mentioned "memory stuff" to her PCP, prompting an was exhausted grunt and a few mouse clicks but no further history taking. The amount of projects and variables she is juggling – by choice, mind you – is staggering. She remembers literally goddamn everything.
She's barely able to restrain herself from writing equations on nearby glass surfaces. I saw her eyeing the back of my head – which is balding – and in a moment of fleeting prescience, I positively knew she wanted to point out how it conformed to the Golden Ratio. Her impulse control and sheer good breeding argue strongly against any sort of frontal process.
Given how high-functioning she appears to be, it's frankly difficult to tell if she has any actual cognitive impairment. If Tesla showed up to my office and reported that he was forgetting to carry the 1 more than usual, I'd have no choice to believe him – but who the fuck could actually tell?
No meds at this point. Frankly, if she is developing dementia, it'll just drag her down to my level. Good.
Defer discussing sweater; this is likely a seasonal issue. Consider addressing this if she wears it again at next visit.
RTC 3 mos
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