The 85-year-old male patient presented with progressive forgetfulness, weight loss, and depressed mood over the past year since his wife's death. His daughter observed deterioration in his memory, concentration, and ability to carry on conversations. Alzheimer's disease is the primary consideration given his age and symptom progression. Differential diagnoses considered include delirium, depression, and hypothyroidism but were deemed less likely based on aspects of his clinical presentation and history.

1. Name: Mel Gibson M. Pajantoy
Block/Subgroup: 4-A
Informant: Daughter of the patient Date: April 28, 2021
% Reliability: 80% Time: 9:15 A.M.
D.P., 85-year-old male, widower, Filipino, Roman Catholic, a retired mechanical engineer, from
Talamban, Cebu City sought consult for the first time in UCMed on April 28, 2021 at 9:15 A.M.
due to forgetfulness
Chief complaint: Forgetfulness
Past History:
Childhood illness includes chickenpox at the age of 13, uncomplicated. Daughter has no record
of his father’s vaccination history but claims that her father had flu and pneumococcal vaccines
last year. Patient is non-diabetic and non-hypertensive. His usual blood pressureis around 140/80
mmHg.Daughter claimedthat his father had a thyroid problem when he was in his 30’s, unrecalled
medicines, compliant. No food and drug allergies. Patient wears eyeglasses. He regularly takes
multivitamins. No other previous hospitalizations nor surgeries, no psychiatric consultations and
treatment. No regular health checkups and screenings. Patient had his last checkup a year ago
and laboratory results were normal.
Family History:
Mother died of old age at 85 years old. She was hypertensive, unrecalled medications. Maternal
heredofamilial disease includes hypertension. Father died when he was 85 due to tuberculosis
and was also hypertensive, unrecalled medications. Paternal heredofamilial diseases include
hypertension and Alzheimer’s disease (uncle). Patient had a younger sibling who died of heart
attack at the age of 70. He is now living with his daughter’s family. Daughter claims that they have
a close interpersonal relationship and that they bond regularly.
Personal and Social History:
Patient is a mechanical engineering graduate and works as an engineer for many years until he
was 65 years old. He works from 9 A.M. to 5 P.M. and daughter claims that his father enjoyed his
work. Patient has only one child, 45-year-old female, healthy and currently living together with the
patient. Regular diet consists of fish and vegetables and consumes at least 2 liters of water per
day. Food supplements include vitamin C, Zinc, and milk (Ensure). Occasionally drinks half to a
bottle of Fundador per occasion. Non-smoker. No history of illicit drug use. Patient’s form of
exercise is when he walks around the house for 15-20 minutes a day with a companion.
HPI:
1 year prior to consult, patient’s daughter initially noted an observable change in her
father’s mood. He was described to be in a depressive state and was forgetful after the death of
his wife.
6 months prior to consult, she then observed weight loss of the patient. Over the course
of 6 months, patient lost approximately 15 lbs in total. Patient was observed be more forgetful,
still depressed, with decreased appetite.. He cannot recall directions, recent events, and the name
of his grandchild. Patient had a tendency to spaced out during conversations. He usually wakes
up from his night sleep 3-4 times. Patient always has a companion wherever he goes, he doesn’t
do any household chores. Daughter observed that his father remains happy, calm, and not
irritated. No other associated signs and symptoms such as fever, vomiting, and headache.

2. 1 week prior to consult, patient’s conditions had not improved. He took melatonin, 6 mg
every night for 1 week. No improvement observed. Persistence of his father’s depressive state
and worsened forgetfulness prompted patient’s daughter to seek for a consultation for his father.
Review of Systems:
General: Weight loss, weakness or fatigue, no fever, no chills.
Skin: No jaundice, no rashes, no edema.
Head, Eyes, Ears, Nose, and Throat (HEENT):
Head: No headache
Eyes: No visual loss, no double vision or yellow sclera, wears eyeglasses.
Ears: Hearing good, no tinnitus, no ear discharges.
Nose: No nasal discharges, no sneezing.
Throat: No dysphagia, no sore throat.
Neck: No lumps, no pain, no swollen glands.
Respiratory: No shortness of breath, no cough or sputum.
Cardiovascular: No palpitations or edema.
GIT: Anorexia, no nausea, no vomiting or diarrhea. No abdominal pain, no blood in stool.
GUT: Nocturia, no dysuria, polyuria, and hematuria.
Musculoskeletal: Back pain, no muscle and joint pain, no stiffness
Psychiatric: No history of depression or treatment for psychiatric disorders
Neurologic: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the
extremities. No change in bowel or bladder control.
Hematology: No anemia, bleeding or bruising.
Lymphatics: No enlarged lymph nodes. No history of splenectomy.
Endocrine: No excessive sweating, cold or heat intolerance. No polyuria or polydipsia.
Allergies: No allergies
Physical Exam:
General Survey: Patient is an elderly man who is accompanied by his daughter. He is alert, with
good eye contact, but cannot speak for his condition due to forgetfulness. Patient is relaxed, not
in respiratory distress with the following vital signs:
BP: 140/90 mmHg Wt: 82 kg
HR: 94 beats/min Ht: 5’6”
RR: 20 breaths/min BMI: 29.1 kg/m2
(Obese)
Temp: 36.4 degrees Celsius
Skin: Dry, fair in color, warm and smooth to touch, good mobility, good turgor, with freckles, no
lesions seen; pink nails, good capillary refill time, no lesions.
HEENT:
Head: normocephalic, symmetrical, fine black hair evenly distributed throughout the head, no
flakes, no scales nor lumps seen on the scalp
Eyes: well aligned with no deviations nor protrusions, eyebrows evenly distributed with no flakes,
equal palpebral fissures, eyelashes directed outwards, pinkish palpebral conjunctivae, anicteric
sclerae, cornea transparent, pupils round, 4mm in both eyes, equally reactive to light, direct and
consensual, full range extraocular muscle movements by Finger Following Test, good
convergence, able to read newsprint with ease at 2 feet distance, both eyes; no visual field defects
by Confrontation test, 20/60 Snellen’s chart
Ears: intact tympanic membranes with good cone of light, no discharges. Cannot hear whispered
voice test at 2 feet in both ears, patient is able to hear spoken voice test at 2 feet in both ears

3. Nose and Paranasal Sinuses: no deformities, no alar flaring, nasal septum midline, no discharges,
no tenderness over the paranasal sinuses, able to transilluminate
Mouth and Pharynx: lips red and moist, buccal mucosa pink, no lesions, complete set of teeth, no
dental carries, tongue midline on protrusion, no lesions, uvula midline, no tonsillopharyngeal
congestion
Neck: trachea midline, no palpable thyroid, no lymphadenopathy, neck veins are not engorged,
no carotid bruits nor thrills
Breasts and axilla: skin uniformly fair, symmetrical, no dimpling, no flattening, no tenderness, no
palpable nodules, nipples everted, no discharges
Chest and Lungs: symmetric, no deformities, no intercostal retraction; equal chest expansion, no
tenderness, equal tactile fremitus; equal resonance in both lung fields; equal vesicular breath
sounds in both lung fields, no adventitious breath sounds, no rales, no crackles, no wheezes,
equal vocal fremitus
Cardiovascular: no visible or palpable parasternal heaves or lifts; PMI at the left 5th
intercostal
space, midclavicular line; normal dullness over precordium on percussion; regular rhythm, no
murmurs and abnormal heart sounds
Abdomen: flat, no scars, no visible vessels, normoactive bowel sounds, generally tympanic, area
of liver dullness: 8cm MCL, 3cm MSL, liver edge smooth and firm palpable 2cm below the costal
margin, (-) abdominal tenderness, no palpable masses
Peripheral vascular system: strong brachial, radial, femoral, popliteal, posterior tibial and dorsalis
pedis pulses, no edema and varicosities, no cyanosis and atrophy
Anus, Rectum, and Prostate: No perirectal lesions or fissures. External sphincter tone intact.
Rectal vault without masses. Prostate smooth and nontender with palpable median sulcus. Stool
brown; no fecal blood
Male genitalia and Prostate: Circumcised male. No penile discharge or lesions. No scrotal
swelling or discoloration. Testes descended bilaterally, smooth, without masses. Epididymis is
nontender. No inguinal or femoral hernias.
Musculoskeletal: Full range of motion in all joints. No evidence of swelling or deformity
Nervous: Oriented to person, place, and time. Minimal Cognitive test: patient remembers 1-2
words out of 3. Patient cannot finish the drawing of clock and cannot determine the specific words.
Cranial nerves II-XII intact. Gait and balance is normal. Sensation intact to pinprick, light touch,
position, and vibration. Reflexes: 2 and symmetric with plantar reflexes downgoing.

4. Primary Impression:
Alzheimer’s disease is the primary consideration since the patient presented with the typical
symptoms of the condition memory loss and depressed mood. Alzheimer’s is a type of dementia
that affects memory, thinking, and behavior. All of these symptoms were observed by the patient’s
daughter for the past year. These symptoms eventually grow severe enough to interfere with daily
tasks. As described by the daughter, the initial manifestation of the patient include forgetting the
usual objects that his father uses such as eyeglasses and remote control. This eventually
progressed to the inability of his father to carry on a conversation and forgetting directions and
names. Alzheimer’s is the most common cause of dementia which is a general term for memory
loss and other cognitive abilities. Another reason to consider Alzheimer’s disease is that most
patients with this disorder usually don’t have other clinical illness. The daughter mentioned that
the recent checkup of his father shows normal findings. Most especially, the greatest known risk
factor for this disease is increasing agent. Patient is already 85 years old
Differential diagnosis:
Delirium can be a differential diagnosis since delirium is a common important disorder that affect
multiple aspects of mental status. Delirium is an abrupt change in the brain that causes mental
confusion and emotional disruption. Patient may experience difficulty to think, remember, sleep,
and pay attention. The following symptoms were also mentioned by the daughter of the patient.
She mentioned that his father had difficulty remembering things, directions, and names. He also
had trouble staying asleep and that’s why she gave him 6 mg of melatonin, but patient condition
did not improve. Other risk factors such as old age and extreme emotional stress could also lead
to delirium. Patient is over 65 years old already and the daughter mentioned that his father’s
condition started after losing his wife. However, delirium are usually acute and always
accompanied by other clinical illnesses and drug toxicity which the patient doesn’t have. Aside
from the tendency to be in a depressed state, patient’s mood in delirium is fluctuating, from fearful
or irritable to normal. Patient’s daughter mentioned that his father remains calm and relax.
Depression is classified as a mood disorder. It typically described as feelings of sadness, loss, or
anger that interfere with a person’s everyday activities. People may experience depression in

5. different ways. In the case of our patient, his wife died a year ago so a possibility of depression is
ruled in. One of the major symptoms of depression that the patient presented include cognitive
abilities such as delayed responses during conversations. Disturbance in the sleep pattern of the
patient and fatigue may also indicate depression. However, the daughter mentioned that his father
remained calm, happy, and relax. Symptoms of depression especially for men almost always
include mood changes such as anger, aggressiveness, irritability, and anxiousness. These are
not consistent with the patient’s profile and symptoms.
Thyroid disease has some symptoms in common with certain mental health conditions. This is
especially true for depression and anxiety. Hypothyroidism is a condition characterized by a
sluggish or underactive thyroid. It is linked most specially to depression in many literatures. The
deficiency of thyroid hormones in the central nervous system can cause fatigue and lack of
energy. These are all symptoms of clinical depression. Patient was observed to be less active
than his usual self. Cognitive dysfunction such as memory loss and difficulty organizing thoughts
are also some of the symptoms of hypothyroidism. The daughter also mentioned that his father a
a history thyroid disease when he was younger so recurrence of the disease might be the reason
for some of his clinical symptoms. However, patient’s laboratory results were normal the year
prior to consult and there is no weight gain which is typically present in a patient with
hypothroidism