Imagine not being able to form new memories. This is the reality patients with anterograde amnesia face. Although this form of amnesia is rare, it can result from severe brain trauma. Anterograde amnesia demonstrates just how impactful brain disorders can be to a patient’s quality of living. Accurately assessing neurological symptoms is a complex process that involves the analysis of many factors.
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. 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 4: 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/focus template and rubric for grading are attached in file
Expert Solution Preview
Introduction:
The patient in this case study, a 67-year-old male, is experiencing forgetfulness, which is affecting his daily life. The following episodic/focused note is designed to evaluate the patient’s symptoms and provide recommendations for appropriate diagnostic tests and potential differential diagnoses based on evidence from the literature.
Episodic/Focused Note:
S – The patient’s daughter reports that her father is very forgetful and has lost his car keys several times. He has also driven to the store and called her for directions to get back home.
O – The patient is a 67-year-old male in apparent good health. The physical examination reveals normal findings. A Mini-Mental State Examination (MMSE) is performed and scores 22 out of 30, indicating mild cognitive impairment.
A – The patient’s symptoms suggest a cognitive impairment, which could potentially be caused by a range of neurological conditions.
P – Diagnostic tests that would be appropriate for this patient include a computed tomography (CT) scan or magnetic resonance imaging (MRI) of the brain to rule out structural abnormalities or vascular conditions that could be contributing to the patient’s forgetfulness. Blood tests, including a complete blood count (CBC), thyroid function tests, and vitamin B12 levels, should be performed to rule out underlying metabolic disorders that could be causing cognitive symptoms.
Differential diagnoses for the patient’s forgetfulness may include:
1. Mild Cognitive Impairment (MCI): MCI is a common condition in older adults, characterized by cognitive decline that is greater than expected for an individual’s age and education level but not severe enough to interfere with daily activities.
2. Alzheimer’s disease: Alzheimer’s is a progressive neurodegenerative disorder that primarily affects memory and cognitive function.
3. Vascular dementia: Vascular dementia is caused by damage to the brain’s blood vessels, which can lead to cognitive symptoms.
4. Lewy Body dementia: Lewy Body dementia is characterized by abnormal deposits of alpha-synuclein protein in the brain, which can cause cognitive symptoms and movement disorders.
5. Frontotemporal dementia: Frontotemporal dementia is a group of disorders that primarily affect the frontal and temporal lobes of the brain, leading to changes in behavior, personality, and language.
Conclusion:
In summary, the patient in this case study is experiencing forgetfulness, which could potentially be caused by a range of neurological conditions. Accurate assessment of neurological symptoms is a complex process that involves the analysis of many factors. Using the Episodic/Focused SOAP Template, healthcare professionals can provide a comprehensive evaluation of a patient’s symptoms, recommend appropriate diagnostic tests, and propose potential differential diagnoses based on evidence from the literature.
