Janet Riley
79 y,'o
5' 7" (170cm)
110_0 1b (50.0 kg)
Chief complaint
Confusion and memory loss reported by
family member
Review
Submitted on
10/12/2020
Case authored by: Alison Reminick, MD
Case Study. Janet Riley V5 PC
Physical ExamAssessmentTestS Diagnosis Plan Summary
cnoose a person to ask:
@ patlent a Janet's daughter
Questions you ask now (after evaluation) dont affect your score.
Choose a category: Or, ask a question. Complete questions work best.
,History
.Snci
Al
(hemoptysis) Can you describe the nature otthe contusion or the types ot memory
loss?
HPIOther (-Z
Complaints
:
Ithereanypattemtowhenyourcontusio
occurs
) n ?
Memory loss
Menstrual irregularities
, DO youhaveaproblemremembering
things
?
HPC Swallowing (hematuria)
problems
(dyspnagja) How severe are your memory problems?
Have you had memory problems before?
HPI: Urinary
Has there been any change in your memory
incontinence
problems over time?
HPI: urination
difficulty
DO your memory problems come and go?
HPI: Urination -
blood
How often do you nave memory problems?
HPI: Is there any pattern to your memory problems?
Have HPI: IJrinary Does anyone in your family nave similar
you incontinence problems with memory loss?
nad What treatments have you had for your memory
any HPI: Urination problems?
difficulty
significant traumatic injuries or
accidents? (Aynnagla)
HPI: urination - blood
(nematuria)
• Have you noticed a decline in your thinking? (patient)
• Has sne noticed a decline in ner thinking? (witness)
Do you have trouble with reasoning, planning, or organizing? (patient)
• Have you dropped many ot your activities and interests? (patient)
• How would you describe your moods? (patient)
• Has there been any change in ner memory problems over time? (witness)
Do you sometimes have trouble remembering things or finding the right names or words? (patient)
Risk Factors:
ptvlH:
Any new or recent change in medications? (witness)
• Does anyone in her family have similar problems witn contusion? (witness)
, HPI/ROS.
When sne urinates, has she noticed any pain, burning, blood, difficulty starting or stopping,
dribbling, incontinence, urgency during day or night, or any changes in trequency? (witness)
• Does sne have any problems witn neadacnes that don't go away witn aspirin or Tylenol (acetaminophen),
double or blurred vision, difficulty with night vision: problems hearing, ear pain, sinus problems,
chronic sore throats, or difficulty swallowing? (witness)
• Does sne experience chest pain discomtort or pressure; pain/pressure/dizziness witn exertion or
getting angry; palpitations; decreased exercise tolerance; or blue/cold fingers and toes? (witness)
• Does sne experience shortness of breath, wheezing, difficulty catching ner breath, chronic cough,
or sputum production? (witness)
• Does sne have any problems witn neat or cold intolerance, increased thirst, increased sweating,
frequent urination, or change in appetite? (witness)
Clinical Feedback
Hx Performance
You asked 99 unique questions 16 were key questionststatements suggested by the expert case
author. You also asked an additional 83 unique questions.
@ Missed Questions
You didn't ask all important questions suggested by the expert author for this case_ You missed asking
25 ot the 41 key questions_(Note: Sometimes there is more tnan one way to get sim/lar information trom
your patient Eliciting information in more than one way when interviewing a patient can De useful.)
Patient's Orientation:
• What time is it? (patient)
• What nappened? (patient)
Chief Complaint Sx/Sx Characteristics:
• Do you feel confused at times? (patient)
• How can I help you today? (patient)
• Does ner confusion come and go? (witness)
• Is there any pattern to when her contusion occurs? (witness)
When did her contusion start? (witness)
• What treatments has she nad tor ner confusion? (witness)
Associated Sx/Sx Characteristics:
• Has she recently had any mood or personality changes? (witness)
• Do you nave a problem remembering things? (patient)
• Have you been depressed? (patent)
79 y,'o
5' 7" (170cm)
110_0 1b (50.0 kg)
Chief complaint
Confusion and memory loss reported by
family member
Review
Submitted on
10/12/2020
Case authored by: Alison Reminick, MD
Case Study. Janet Riley V5 PC
Physical ExamAssessmentTestS Diagnosis Plan Summary
cnoose a person to ask:
@ patlent a Janet's daughter
Questions you ask now (after evaluation) dont affect your score.
Choose a category: Or, ask a question. Complete questions work best.
,History
.Snci
Al
(hemoptysis) Can you describe the nature otthe contusion or the types ot memory
loss?
HPIOther (-Z
Complaints
:
Ithereanypattemtowhenyourcontusio
occurs
) n ?
Memory loss
Menstrual irregularities
, DO youhaveaproblemremembering
things
?
HPC Swallowing (hematuria)
problems
(dyspnagja) How severe are your memory problems?
Have you had memory problems before?
HPI: Urinary
Has there been any change in your memory
incontinence
problems over time?
HPI: urination
difficulty
DO your memory problems come and go?
HPI: Urination -
blood
How often do you nave memory problems?
HPI: Is there any pattern to your memory problems?
Have HPI: IJrinary Does anyone in your family nave similar
you incontinence problems with memory loss?
nad What treatments have you had for your memory
any HPI: Urination problems?
difficulty
significant traumatic injuries or
accidents? (Aynnagla)
HPI: urination - blood
(nematuria)
• Have you noticed a decline in your thinking? (patient)
• Has sne noticed a decline in ner thinking? (witness)
Do you have trouble with reasoning, planning, or organizing? (patient)
• Have you dropped many ot your activities and interests? (patient)
• How would you describe your moods? (patient)
• Has there been any change in ner memory problems over time? (witness)
Do you sometimes have trouble remembering things or finding the right names or words? (patient)
Risk Factors:
ptvlH:
Any new or recent change in medications? (witness)
• Does anyone in her family have similar problems witn contusion? (witness)
, HPI/ROS.
When sne urinates, has she noticed any pain, burning, blood, difficulty starting or stopping,
dribbling, incontinence, urgency during day or night, or any changes in trequency? (witness)
• Does sne have any problems witn neadacnes that don't go away witn aspirin or Tylenol (acetaminophen),
double or blurred vision, difficulty with night vision: problems hearing, ear pain, sinus problems,
chronic sore throats, or difficulty swallowing? (witness)
• Does sne experience chest pain discomtort or pressure; pain/pressure/dizziness witn exertion or
getting angry; palpitations; decreased exercise tolerance; or blue/cold fingers and toes? (witness)
• Does sne experience shortness of breath, wheezing, difficulty catching ner breath, chronic cough,
or sputum production? (witness)
• Does sne have any problems witn neat or cold intolerance, increased thirst, increased sweating,
frequent urination, or change in appetite? (witness)
Clinical Feedback
Hx Performance
You asked 99 unique questions 16 were key questionststatements suggested by the expert case
author. You also asked an additional 83 unique questions.
@ Missed Questions
You didn't ask all important questions suggested by the expert author for this case_ You missed asking
25 ot the 41 key questions_(Note: Sometimes there is more tnan one way to get sim/lar information trom
your patient Eliciting information in more than one way when interviewing a patient can De useful.)
Patient's Orientation:
• What time is it? (patient)
• What nappened? (patient)
Chief Complaint Sx/Sx Characteristics:
• Do you feel confused at times? (patient)
• How can I help you today? (patient)
• Does ner confusion come and go? (witness)
• Is there any pattern to when her contusion occurs? (witness)
When did her contusion start? (witness)
• What treatments has she nad tor ner confusion? (witness)
Associated Sx/Sx Characteristics:
• Has she recently had any mood or personality changes? (witness)
• Do you nave a problem remembering things? (patient)
• Have you been depressed? (patent)
