Marguerite D.

Care manager call with the patient's daughter Jul 24, 2026, eighteen minutes, patient on the line for the first six. Two unwitnessed falls this month, neither with injury, both in the hallway at night. Daughter reports word finding has become noticeably worse since June and that her mother has started substituting "that thing" for objects she named without difficulty in the spring. Bathing now requires standby assistance, which is new. Caregiver strain screen elevated, daughter is sleeping in the house four nights a week and has stopped her own physiotherapy.

The patient herself was pleasant and oriented to person and place, not to date. Speech was noticeably more effortful than the June call. Clarity read articulatory precision down fourteen points across six weeks, the steepest single domain move in her record, and the drop is on the motor speech axis rather than the retrieval axis. That pattern plus new gait instability and atrial fibrillation on anticoagulation is a different concern from steady Alzheimer's progression. Full care manager call transcript.

Plan: urgent MRI brain to exclude interval infarct, arranged same week. In person review with Dr. Barrera within seven days. Home safety evaluation and night lighting, referral placed. Physiotherapy for gait and falls. Respite hours activated through GUIDE, daughter offered the full $2,500 annual benefit and accepted eight hours a week. Medication review for anything sedating.

MRI brain without contrast, Jul 29, 2026, obtained urgently on the strength of the articulatory precision drop, the new falls and her anticoagulation. Findings: a small subacute lacunar infarct in the left corona radiata measuring seven millimetres, with restricted diffusion and corresponding FLAIR signal. Background of confluent periventricular and deep white matter hyperintensity, Fazekas grade 3. Moderate generalized and medial temporal atrophy, Scheltens 3, stable from the March 2025 study. No haemorrhage on susceptibility weighted imaging, no mass, no hydrocephalus.

Impression: new small vessel infarct on a background of severe chronic small vessel disease and known Alzheimer's type atrophy. The acute finding accounts for the interval speech change and the gait deterioration. Anticoagulation reviewed with cardiology and continued. This scan was ordered eleven days earlier than her scheduled review because of the voice trend.