Master NR 601: i-Human Ella West (Confusion &
Memory Loss) Full Case Study & SOAP Note |
Chamberlain University 2025-2026 A+ Guide
,Patient Overview
• Name: Mrs. Ella West
• Age: 79 years
• Sex: Female
• Informant: Daughter (reliable historian)
• Reason for Encounter: Progressive confusion and
memory loss over the past week
• Living Situation: Resides with daughter, who is her
primary caregiver
• Occupation: Retired librarian
• Advance Directives: None documented; family to be
counseled
History of Present Illness (HPI)
Mrs. West's daughter reports a noticeable decline in her
mother's cognitive function over the past 5–10 days,
characterized by:
• Increased confusion
• Difficulty recalling recent events
• Occasional disorientation regarding time and place
, The patient denies experiencing any physical symptoms
such as headache, dizziness, or visual disturbances. There
is no history of recent trauma or significant stressors.
Past Medical History (PMH)
• Hypertension
• Hyperlipidemia
• Coronary Artery Disease (CAD)
• Insomnia
Diagnostic Workup
• MRI Brain: Generalized cortical atrophy with
reduced hippocampal volume, suggestive of early
Alzheimer's disease or other neurodegenerative
conditions (Course Hero).
• Mini-Mental State Examination (MMSE): Score of
22/30, indicating mild cognitive impairment.
• Laboratory Tests: Normal complete blood count
(CBC), thyroid function tests, and vitamin B12
levels.
Differential Diagnosis
Memory Loss) Full Case Study & SOAP Note |
Chamberlain University 2025-2026 A+ Guide
,Patient Overview
• Name: Mrs. Ella West
• Age: 79 years
• Sex: Female
• Informant: Daughter (reliable historian)
• Reason for Encounter: Progressive confusion and
memory loss over the past week
• Living Situation: Resides with daughter, who is her
primary caregiver
• Occupation: Retired librarian
• Advance Directives: None documented; family to be
counseled
History of Present Illness (HPI)
Mrs. West's daughter reports a noticeable decline in her
mother's cognitive function over the past 5–10 days,
characterized by:
• Increased confusion
• Difficulty recalling recent events
• Occasional disorientation regarding time and place
, The patient denies experiencing any physical symptoms
such as headache, dizziness, or visual disturbances. There
is no history of recent trauma or significant stressors.
Past Medical History (PMH)
• Hypertension
• Hyperlipidemia
• Coronary Artery Disease (CAD)
• Insomnia
Diagnostic Workup
• MRI Brain: Generalized cortical atrophy with
reduced hippocampal volume, suggestive of early
Alzheimer's disease or other neurodegenerative
conditions (Course Hero).
• Mini-Mental State Examination (MMSE): Score of
22/30, indicating mild cognitive impairment.
• Laboratory Tests: Normal complete blood count
(CBC), thyroid function tests, and vitamin B12
levels.
Differential Diagnosis
