History of Present Illness The patient is a 77 year old man with past medical history significant for dementia, hyperlipidemia, coronary artery disease (CAD), s/p coronary artery bypass graft (CABG) and aortic valve replacement (AVR) who was referred to the Memory Clinic for agitation.
According to the patient’s family member, he started having memory problems in 2002, which worsened significantly after his CABG and AVR in 2004. At the time he presented to the clinic, he had functional deficits in the following instrumental activities of daily living (IADLs) – handling finances, driving, cooking and shopping. The patient was noted to be easily agitated and irritable for sometime, and was referred to the Memory Clinic for exhibiting verbal and physical aggression towards his wife as well as others. The patient was recently seen by his primary care physician for this issue, and all of his laboratory exams were normal, and subsequent MRI of the brain was also unremarkable.
The patient noted good appetite and denied problems with sleeping or weight changes. He also denied any suicidal ideations and visual/auditory hallucinations. However, he stated that he was depressed because he was worried about his memory problems.
Assessment and Plan The patient had few typical symptoms of depression, however had agitation and irritability noted by his wife in addition to depressed mood expressed by the patient. In this ease, the patient may be minimizing or is unaware of his symptoms due to his dementia. The doctor ordered a Chest X-Ray due to hearing rails in the lungs and an Elbow X-Ray due to the patient not allowing the doctor to extend the patient’s arm.

Questions:
1. The patient is in the waiting room. How do you call the patient for their exam? (Remember HIPAA)
2. Once in the room, how do you introduce yourself and the exam?
3. How do you approach a patient that is difficult? If the patient will not extend their arm, how do you get the images the doctor has asked for?
4. How would you show empathy? (Remember, the patient has a caretaker/family member with them)