Sample Case (Alzheimer’s)

History of Present Illness

Alice is a 66-year-old Caucasian female, who presents to the neurology department after being
referred by her primary care provider for complaints of mood swings and memory problems.
Patient states, “I’ve been forgetting things. Yesterday, I couldn’t remember my dog’s name. I
was trying to call her to come in and I just stood there staring at her for a good long time. It was
very scary.”  The patient reports that she sometimes has difficulty thinking of the words she
needs to express herself.  She is also concerned that she is forgetful, frequently misplacing
objects or forgetting what she was doing.  The patient is not overly concerned about these
symptoms, stating, “Usually, I’m just fine.  My husband is the one who wanted me to come.” 
Alice’s husband reports that he has noticed her to repeat herself and forget more prominent
details, and that it seems to be getting worse.  

Alice states that she first noticed some vague symptoms several years ago, however they have
become more frequent over the past 5-6 months.   Her husband and she agree that she has not
had any problems performing her daily living tasks or other regular activities.   They both report
mood swings starting in the last two months. When asked for further details, Alice replies, “I just
seem to get frustrated or irritated easily.”