Reason for visit: The patient is 40 year old male who has been diagnosed with Alzheimer Disease. The condition has been diagnosed by his personal doctor and therefore been referred to an outpatient clinic.
HPI: The patient in this case was diagnosed a month earlier with the illness. He is unable to remember the important parts of his medical history hence the daughter helps with these vital information. The symptom of the disease was also noticed around the same time yet they were mild. The patient occasionally forgot where he placed his car keys and could not remember the name of his granddaughter.
ROS: The patient is states that he is a good condition since home. The patient also denies the fact that there might be a similar case of dementia in the family which might be associated with his illness. In addition to that, the patient also denies having stroke, depression, head injury, diabetes, or high blood pressure.
PMS/PSH: Before admission, the daughter confirmed that the patient was a heavy smoker and also suffered from depression. His condition with depression was treated with Prozac. Additionally, the patient had to do several therapy sessions to fight his addiction to smoking.
Meds and allergies: The patient was instructed to use galantamine, rivastigmine, and donepezil since his conditions was still mild (Andrade-Guerrero et al., 2023). The patient has no allergies to any of these drugs hence they should be consumed as prescribed.
Social/habits/other: The patient is divorced and lives with the daughter. He works as a truck driver and since he was out of rehab there is no any other history of drug or substance abuse.
Family history: there is no any family history of Alzheimer in parent or sibling.
Physical exam: BP 130/80, regular pulse.
Assessment/plan: Vascular screening-AAA screening ultra sound. Use donepezil, one tablet a day. Lastly, return to clinic after 3 months to check on progress.
Reference
Andrade-Guerrero, J., Santiago-Balmaseda, A., Jeronimo-Aguilar, P., Vargas-RodrĂguez, I., Cadena-Suárez, A. R., Sánchez-Garibay, C., Pozo-Molina, G., MĂ©ndez-Catalá, C. F., Cardenas-Aguayo, M.-del-C., Diaz-Cintra, S., Pacheco-Herrero, M., Luna-Muñoz, J., & Soto-Rojas, L. O. (2023). Alzheimer’s disease: An updated overview of its genetics. International Journal of Molecular Sciences, 24(4), 3754. Web.