Neurocognitive Disorder
HISTORY:
for
Specific difficulties:
Onset:
Impact on daily activities:
Worsening factors:
Treatments tried: ,
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Measurements: weight: kg, height: cm, waist: cm, BMI:
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:
- Blood work: , , , , , , , , , ,
- Urinalysis
- CT scan of the head
- MRI of the head
- Neuropsychological evaluation
- Lumbar puncture if infection or prion disease suspected
- Psychoeducation about neurocognitive disorders
- Cognitive exercise
- Regular physical exercise
- Balanced diet
- Regular sleep schedule
-
-
-
-
- Home safety assessment
- Occupational therapy
- Physical therapy
- Further information to obtain from family
- Referral to geriatrician
- Referral to neurologist
- Referral to social worker
- Follow-up in
- Return if symptoms worsen or if new symptoms develop such as confusion, memory loss, or changes in behavior or mood