i-Human Case Sophia King Answers

Week 3: Sophia King

79 y/o

5′ 4″ (163 cm)

110.0 lb (50.0 kg)

Reason for encounter

Confusion and memory loss reported by family member

Location

Outpatient clinic with x-ray, ECG, and laboratory capabilities

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Interview History Questions for Sophia King/ Janet Riley

Does she feel she has more memory problems than others (witness)
How severe are her memory problems (witness)
Do you have trouble with reasoning, planning, or organizing (patient)
Is she having trouble concentrating or making decisions well? If so, how often (witness)
Are you having trouble concentrating or making decisions well? If so, how often (patient)
When did her trouble concentrating or making decisions start (witness)
Over the past two weeks, how often has she been bothered by feeling down, depressed, or hopeless? (witness)
Over the past two weeks, how often has she been bothered by having little interest or pleasure in doing things (witness)
………….
Physical Exams Required

Weight
Height
cognitive status
SpO2
temperature
blood pressure
pulse
respiration
temperature
auscultate heart
auscultate lungs…….
Differential Diagnoses

Dementia, Alzheimer’s
Dementia, vascular
Major depressive disorder
Encephalopath
………
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Diagnosis: Alzheimer’s disease (moderate) with possible vascular component

Diagnostic Tests:

Brain MRI: generalized cortical atrophy, reduced hippocampal volume R>L, no evidence of infarctions
Complete blood count: normal
Comprehensive metabolic panel: normal
Folate: normal
Free T4: normal
HIV: negative