Chapter 7: The Nervous System | Steven Rutter's Chart Note

CHART NOTE

Patient Name: Rutter, Steven
ID Number: 257RS
Examination Date: December 6, 20xx

SUBJECTIVE
Mr. Rutter is an anxious 84-year-old gentleman who appears older than his stated age. He states that he has been experiencing increasing episodes of memory loss.

OBJECTIVE
Physical exam reveals an agitated but depressed-appearing male who is underweight but in no acute distress. He denies any falls or head injuries. He has a history of TIAs and a CVA that occurred 3 years ago. Vital signs normal. Cranial nerves II through XII are intact in detail to visual fields and ophthalmoscopic (pertaining to an instrument used to visualize the eyes) examination. Motor and sensory exams and reflexes within normal limits.

ASSESSMENT
Patient has memory loss without objective findings relating to organic (causing a change in physical structure) etiology. Depression may be a key factor. Rule out dementia.

PLAN
I will order a CT scan of the brain. Pending results may necessitate a neurology consult.