We’ll write everything from scratch Question  Assessment of Cognition and the Neurologic System 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. 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. 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

Assessment of Cognition and the Neurologic System

Patient Information:

Initials: J.S.

Age: 67

Sex: Male

Race: Caucasian

S.

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.

O.

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 auscult