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Neurocognitive Disorder

HISTORY:
 for  
Specific difficulties: 
Onset: 
Impact on daily activities: 
Worsening factors: 
Treatments tried: , 




















Activities of Daily Living (ADL):
Instrumental Activities of Daily Living (IADL):
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
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- 
- 
- 
- 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