Using the information given in the case notes, write a letter of referral to Dr. Jones at the Newton Memory Clinic, 400 Rail Road, Newton, to provide him with your brief assessment and request full memory assessment and diagnosis.
In your assessment:
- Explain the relevant notes in complete sentences.
- Do not use note form
- Use letter format
180 to 200 words.
Newton Memory Clinic
400 Rail RD
Re: Patricia Welshman, DOB: 28/03/1930
I am writing to refer this patient, an 85-year-old widow who I suspect of having early-stage Alzheimer’s disease and requires full memory assessment and diagnosis.
(Well, I still think you should avoid giving the diagnosis in the introduction. This is a place to write SYMPTOMS, not a diagnosis. It can be restructured as: I am referring Mrs. Welshman, an 85 years old widow, who suffers from poor memory.)
Mrs. Welshman is under my care since 2007.
In regards to her social history, she lives alone with her children nearby (This is not history. This is present. She lives alone and her children live within 10 kilometers of her residence.). She has osteoporosis and dementia and is currently under Osteovit-D, Lipitor, Brufen, Metrol and Panadol (I don’t know what these medicines are for, but you need to connect these to High LDL and low vitamin D to build a case for memory loss). Furthermore, she has a family history of Alzheimer’s disease.
She suffers from osteoporosis and dementia. Though she has been advised to consume O, L, B, M, and P, I suspect whether she is taking the medication regularly. In December 2014, she had a high LDL and a low vitamin D despite these medications. Moreover, she was reluctant to use the Weber pack and promised to adhere to the medication. Further examination in February 2015 revealed that while her vitamin D had drastically fallen, total cholesterol had increased. (connect the dots between December 2014 and February 2015 to build a case for Alzheimer’s.)
On her visit in the surgery on 14/12/2014, she had a high LDL and low vitamin D level despite being on medications. She also had spare scripts and on counseling promised to adhere to her medications. After two months, she had similar blood reports and hence she was advised to use Webster pack, for which she agreed. (This is exactly what happened. But you need to connect the dots and build the case as I’ve tried to do above.)
On review today, After using the Weber pack, her laboratory reports are were normal today. Her poor memory is also evident in forgetting routine activities such as dinner arrangements. This is further reinforced by the mini memory assessment which revealed poor short-term memory However, she demonstrates a poor memory along with behavioral changes, regarding which her daughter is concerned. Mini memory assessment revealed poor short-term memory.
In view of above signs and symptoms, I believe she needs further memory assessment and a diagnosis for Alzheimer’s disease. I would appreciate your assessment of her condition.