A 78-Year-Old Woman Comes to the Physician Accompanied by Her

question 609

Multiple Choice

A 78-year-old woman comes to the physician accompanied by her daughter to establish primary care.  The patient has just relocated to the area and moved in with her daughter.  The daughter feels that her mother is no longer able to live independently and is concerned about some forgetfulness and falls that her mother has experienced.  After the last fall she was seen in the local emergency department, had a normal head CT scan, and was discharged home.  The patient relates a history of insomnia, depression, osteoporosis, osteoarthritis, chronic dizziness, hypertension, atrial fibrillation, "early" Alzheimer's, and urinary incontinence.  She performs all her own activities of daily living but requires help with bathing.  Her current medications include amitriptyline, warfarin, diphenhydramine at bedtime, meclizine, oxybutynin, calcium, vitamin D, alendronate, and lisinopril.
On examination, she is a well-dressed, pleasant, frail-looking elderly woman in no distress.  Her blood pressure is 140/90 mm Hg and pulse is 84/min and irregular.  Her lungs are clear on auscultation.  The abdomen is soft and non-tender.  Her gait is slow but normal.  There are no focal defects on neurological examination.  Her score on a Mini-Mental State Exam is 25/30.
She brings with her a print-out of a recent INR (2.6) performed by her previous primary care provider.
Which of the following is the best next step in managing this patient?

• A)Brain MR imaging
• B)Hearing and vision evaluation
• C)Review of home environment
• D)Review of medications
• E)TSH, vitamin B₁₂, and vitamin D levels

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