Memory Loss
HISTORY:
Memory loss for
Specific difficulties:
Onset:
Impact on daily activities:
Worsening factors:
Treatments tried: ,
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Neck:
Heart: ,
Lungs: ,
Abdomen: , , ,
Neurologic:
- Mental status: , oriented in , speech
- Cranial nerves:
- Strength: upper extremities -R /5 , -L /5
lower extremities -R /5 , -L /5
- Sensation: upper extremities -R , -L ,
lower extremities -R , -L
- Reflexes: triceps -R , -L , biceps -R , -L , brachioradialis -R , -L
patellar -R , -L , achilles -R , -L , plantar -R , -L
- Cerebellar function: , finger-nose , rapid alternating movements , heel-knee , Romberg , Dix-Hallpike ,
- Gait: , tandem walking , heel and toe walking
Mental status: , , speech , mood , thought process , , judgment
ASSESSMENT:
DDx:
PLAN:
- Mini-mental state exam
- Blood work: , , , , , , , , , ,
- CT scan of the brain
- MRI of the brain
- Lumbar puncture
- Reassessment of medications
- Stop medications that may contribute to condition {(e.g. anticholinergics, benzodiazepines, opioids, antihistamines, antipsychotics)}
- Dispill packaging
- Avoidance of alcohol
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- Cognitive stimulation therapy
- Occupational therapy for cognitive assessment
- Occupational therapy for functional assessment
- Home safety assessment
- Driving assessment
- Complete history with family members
- Referral to geriatrician
- Referral to neurologist
- Referral to neuropsychologist
- Referral to social worker
- Follow-up in
- Return if memory loss worsens or if new symptoms develop such as confusion, personality changes, or difficulty with daily activities