Lorenzo Year Female Question & Answer Guide (With Explanation)
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Original Question
Ms. Lorenzo is a 72-year-old female who is brought to your office by her son with reports of acute confusion (more than usual) and some agitation and restlessness. She has a known history of dementia, managed with Aricept 10 mg. daily. Her son and primary caregiver, Jack, reports that 2 days ago she began to become more confused than usual and very easily agitated. He reports that yesterday, she couldn’t remember where she was in her own home. She had a doctor’s appointment 3 days ago and her HCTZ (hydrochlorothiazide) was increased to 50 mg. due to increased blood pressure. Ms. Lorenzo’s last Mini-Mental State Exam (MMSE) score was 18/30. The assessment was repeated at her appointment 3 days ago, and the score remained unchanged. Ms. Lorenzo and her son deny her having any falls or contributing traumas recently. She denies any changes in diet or routine regimens. No reported dysuria, no fever, nausea, or vomiting. Note: Be sure to review the MMSE and how to interpret results (Mental State Assessment Tests). Make sure you present the patient’s score in your video presentation posted in discussion. Also review the Geriatric Depression Assessment (Geriatric Depression Scale [GDS]). Ms. Lorenzo is a 72-year-old female who is alert but easily distracted, at times, during today’s clinical interview. Her eye contact is fair. Speech is clear and coherent but tangential at times. She makes no unusual motor movements and demonstrates no tics. She denies any visual or auditory hallucinations. She denies any suicidal thoughts or ideations. She is alert but disoriented to place and time. She denies any falls, denies any pain. Her son does say she has had some “stumbling” and balance issues but no reported falls. All other Review of System and Physical Exam findings are negative other than stated. Vital Signs: Temp 98.1 BP 120/64 HR-72 Resp 20 PMH: Hypertension, Diabetes, Chronic Allergic Rhinitis, Recurrent UTI’s Allergies: Atorvastatin – muscle pain Medications: Multivitamin PO daily Losartan 50mg PO daily HCTZ 50mg PO daily Fish Oil 1 tablet PO daily Glyburide 5mg PO daily Metformin 500mg PO BID Donepezil 10mg PO daily Social History: As stated in Case Study ROS: As stated in Case Study Diagnostics/Assessments done: CXR—no cardiopulmonary findings. WNL CT head—diffuse Cerebral Atrophy MMSE—Ms. Lorenzo scored 18 out of 30 with primary deficits in orientation, registration, attention and calculation, and recall at her visit 3 days ago. The score suggests moderate dementia. She is unable to pay attention at this visit to complete another assessment. Hemoglobin A1C 7.2% UA – yellow, clear, pH 5, Spec Gr 1.010, Blood Neg, Glucose Neg, Ketones Neg, Leukocytes Neg, Nitrite Neg, WBC’s Neg. Basic Metabolic Panel as shown below TEST RESULT REFERENCE RANGE GLUCOSE 90 65-99 SODIUM 130 L 135-146 POTASSIUM 3.2 L 3.5-5.3 CHLORIDE 104 98-110 CARBON DIOXIDE 29 19-30 CALCIUM 9.0 8.6-10.3 BUN 20 7-25 CREATININE 1.00 0.70-1.25 GLOMERULAR FILTRATION RATE (eGFR) 77 >or=60 mL/min/1.73m2
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