example write up 1

Clinical Case

Mr.Johnson is a very pleasant 87 y.o. male who presents to the clinic today for his annual follow up.  Mr.Johnson has a PMH of hypothyroidism, HTN but otherwise healthy. He reported that he was doing well other than being frustrated about his memory giving him problems recently. He stated he was microwaving his food the other day and forgot how to open the microwave back up to get his food out. He is still very active and volunteers at a nursing home but is having some difficulty driving to these locations. He gets lost easily and has to try really hard to remember where he is going. It takes him longer to remember even things like the current date and month. He reports being very frustrated by this but otherwise reports no other problems. He lives with his daughter at home.

Problem List

Structure and Processes of Care – Pt is a very active and very independent even in this stage of his life. Pt lives with daughter at home with minimal help but that is changing slowly. Pt is increasingly requiring more help with everyday activities.  

·         Changing home situation

Physical Aspects of Care –Pt reports occasional fatigue but otherwise is doing well.

·         HypothyroidismàAsymptomatic, TSH-wnl,  taking levothyroxine

·         HTNàBP 130/70 today, taking HCTZ

Psych Aspects of Care –Pt is very anxious and frustrated by declining memory function and becoming increasing dependent on his daughter. Pt is afraid that he will not be able to drive anymore and that will have a major adverse effect on his life. Pt enjoys volunteering in the community and is expecting that he won’t be able to continue such activities.

·         Anxiety, worried

Social Aspects of Care – Pt lives with his daughter and is worried about bothering her increasing care giver needs.

·         Relationship with daughter

Ethical & Legal Aspects of Care-Pt is still driving and is a potential danger to himself and others on the road. Pt also needs to appoint DPOA and lay out clear goals of care since his mental status is starting to decline.

·         Driving situation

·         DPOA

·         Goals of care

Geriatric Competencies

COGNITIVE, AFFECTIVE, AND BEHAVIORAL HEALTH

4. Mr. Johnson’s sx’s were alarming for onset of dementia so I found it appropriate to administer a Mini Mental Status Exam.  Pt scored 16 points out of 30 and had trouble with almost all categories of the test such as orientation, recall, attention, calculation and language manipulation.

7. After completion of Mr.Johnson’s evaluation, it was found appropriate to start him on Aricept. He was also referred to a neurologist for further work up and evaluation. Thyroid function was found to be normal and Vitamin B12 levels were ordered to rule out other causes.

AMBULATORY CARE

24. A thorough discussion was had with Mr.Johnson and his daughter about Mr.Johnson no longer driving. Mr.Johnson was very disappointed in this outcome but understood that his safety as well as of others could be compromised if he continued to drive. The discontinuation of driving was a temporary move to be further evaluated by the neurologist after full evaluation of the patient.

Relevant Literature

The MMSE test is the most widely used test to initially evaluate dementia in the U.S. [1,2].  It has shown to be useful and effective with a   87% sensitivity and 82% specificity of a cut of score of 24 is used. But studies of the test have shown it to not be as effective for mild dementia and for people with limited education. In some studies the score has been shown to go down as the level of education of the participants goes down[3].  That is why it is important to identify the pattern of deficiency on the test for any particular patient as to identify any biases leading to false results.

Aricept acts as a cholinesterase inhibitor to increase overall cholinergic activity in the brain. In randomized trials, it has shown modest benefit as compared to placebo. The effect, when the drug is withdrawn, diminishes as such demonstrating that the drug has no effect on the underlying mechanism of the progression of the disease [4]. Although it is important to note that while it did slow down the progression of disease, studies showed that it did not change the timeline of when the pt will need entry into institutionalized care [5].

This information is very helpful as we try to continue our care for Mr.Johnson. He will likely need more assistance at home and if the daughter is unable to provide the care needed then discussions would need to be had about home health vs. transferring to independent living center. Pt should also be monitored closely for depression as these life changes are going to be adverse to his social life and depression can be difficult to distinguish in the setting of dementia. Mr.Johnson will need close f/u to make this transition of care as easy as possible for him and to maximize the remaining healthy years of his life.

 

Works Cited


1. “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician,

Folstein MF, Folstein SE, McHugh PR, J Psychiatr Res. 1975;12(3):189.

 

2. The Mini-Mental State Examination in general medical practice: clinical utility and acceptance.

Tangalos EG, Smith GE, Ivnik RJ, Petersen RC, Kokmen E, Kurland LT, Offord KP, Parisi JE

Mayo Clin Proc. 1996;71(9):829.


3. Population-based norms for the Mini-Mental State Examination by age and educational level.

Crum RM, Anthony JC, Bassett SS, Folstein MF, JAMA. 1993;269(18):2386.


4. Long-term donepezil treatment in 565 patients with Alzheimer’s disease (AD2000): randomised double-blind trial.

Courtney C, Farrell D, Gray R, Hills R, Lynch L, Sellwood E, Edwards S, Hardyman W, Raftery J, Crome P, Lendon C, Shaw H, Bentham P, AD2000 Collaborative Group Lancet. 2004;363(9427):2105.

5. Efficacy of donepezil on maintenance of activities of daily living in patients with moderate to severe Alzheimer’s disease and the effect on caregiver burden. Feldman H, Gauthier S, Hecker J, Vellas B, Emir B, Mastey V, Subbiah P, Donepezil MSAD Study Investigators Group J Am Geriatr Soc. 2003;51(6):737.

*All names appearing in this work are fictitious. Any resemblance to real persons, living or dead, is purely coincidental.