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Patient Ms Ameena came to a specialty memory clinic at the age of 68 with a 2-year history of repetitiveness, memory loss, and executive function loss. Magnetic Resonance Imaging scan at age 68 revealed a mild generalized cortical atrophy. She worked as a manager in telecommunication and retired from employment at the age of 58. She was working before because of family financial needs and not because of cognitive challenges with work. Progressive cognitive decline was evident by the report of deficits in the performance of instrumental activities of daily living over the past 9 months before her initial consultation in the memory clinic. Word finding and literacy skills were noted to have deteriorated in the preceding 6 months according to her spouse. Examples of functional losses were as follows: being slower in processing and carrying out instructions; not knowing how to turn off the stove; and becoming unable to assist in boat docking which was the couple’s pastime. She stopped driving a motor vehicle about 6 months before her memory clinic consultation. Her past medical history was relevant for hypercholesterolemia and vitamin D deficiency. She had no surgical history. She had no history of smoking, alcohol, or other drug misuse. Laboratory screening was normal. There was no first-degree family history of presenile dementia. Neurocognitive assessment at the first clinic visit revealed a Mini Mental State Examination (MMSE) score of 14/30; poor verbal fluency (patient was able to produce only 5 animal names and 1 F-word in 1 min) as well as poor visuospatial and executive skills. She had fluent speech without semantic deficits. Her neurological examination was pertinent for normal muscle tone and power, mild ideomotor apraxia on performing commands for motor tasks with no suggestion of cerebellar dysfunction, normal gait, no frontal release signs. Her speech was fluent with obvious word finding difficulties but with no phonemic or semantic paraphrasic errors. Her general physical examination was unremarkable without evidence of presenile cataracts. She had normal hearing. There was no evidence of depression or psychotic symptoms.

 

 

Problem-Focused Assessment Write-up 

I – Focus Assessment

Biographic Data (1 mark)

 

Chief complaints (1 mark)

 

History Of Present Illness (4 marks)
Past Medical History (1 mark)
Family History (1 mark)
Occupational History (1 mark)

II- Physical Assessment (11 marks)

Head to Foot Assessment (3 marks)
Neurological including Sensory Assessment (3 marks)
Mental status examination (5 marks)

 

 

 

III – NURSING CARE PLAN (SOAP)

 

 

SUBJECTIVE

 (5 Marks)

 

 

 

 

 

OBJECTIVE

(5 Marks)

 

 

 

 

 

 

 

ASSESSMENT

(5 Marks)

 

 

 

 

 

 

PLAN

(5 Marks)

 

 

 

 

 

 

SCIENCE
HEALTH SCIENCE
NURSING
NURSING 101