lOMoARcPSD| 67215951
l
,lOMoARcPSD| 67215951
, lOMoARcPSD| 67215951
History of Present Illness
Reason for Encounter Confusion and memory loss.
History of present illness J.R. is a 79-year-old female, retired teacher.
Accompanied by her daughter. Daughter voices
concern over her mother’s increasing confusion,
memory loss, and ability to complete ADLs and
IADLs. Daughter reports that pt’s forgetfulness
and confusion started 2-3 years ago but has
progressively worsened over the past year. The
patient is no longer cleaning her home, doing
laundry, or maintaining her personal hygiene. She
is forgetting to pay her bills, has missed her exit
on her way home, and is forgetting the names of
neighbors and acquaintances. The patient has
lost interest in her usual activities, and exhibits
increased irritability, paranoia, and anxiety. She
has had an 8-pound unintentional weight loss
over the past few months. Confusion is described
as constant, with no alleviating factors, but is
worsened when the patient becomes more
agitated. The patient has not seen any other
providers for this problem and has not tried any
treatments. She denies any new prescription or
OTC
l
,lOMoARcPSD| 67215951
, lOMoARcPSD| 67215951
History of Present Illness
Reason for Encounter Confusion and memory loss.
History of present illness J.R. is a 79-year-old female, retired teacher.
Accompanied by her daughter. Daughter voices
concern over her mother’s increasing confusion,
memory loss, and ability to complete ADLs and
IADLs. Daughter reports that pt’s forgetfulness
and confusion started 2-3 years ago but has
progressively worsened over the past year. The
patient is no longer cleaning her home, doing
laundry, or maintaining her personal hygiene. She
is forgetting to pay her bills, has missed her exit
on her way home, and is forgetting the names of
neighbors and acquaintances. The patient has
lost interest in her usual activities, and exhibits
increased irritability, paranoia, and anxiety. She
has had an 8-pound unintentional weight loss
over the past few months. Confusion is described
as constant, with no alleviating factors, but is
worsened when the patient becomes more
agitated. The patient has not seen any other
providers for this problem and has not tried any
treatments. She denies any new prescription or
OTC
