Memory Loss
Age: years old
Gender:
HISTORY:
Presents with a - history of memory loss
Specific difficulties:
Onset:
Impact on daily activities is
Worsening factors:
Alleviating factors: ,
Associated symptoms: *Try using right-click for negatives*
, over ,
Contributing factors:
no history of: , , , , , ,
no use of: , , ,
no family history of: ,
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Neck: , , , c-spine
Heart: , ,
Lungs: , ,
Abdomen: , , ,
Neurologic:
- Mental status: , oriented to , speech
- Cranial nerves:
- Strength: except for on ,
- Sensation: to on
- Reflexes: except for on ,
- Cerebellar function: , finger-nose, rapid alternating movements, heel-shin, Romberg , Dix-Hallpike
- Gait: , tandem gait, heel walk and toe walk
Mental status: , , speech , mood , thought , , judgment
ASSESSMENT:
DDx: age-related cognitive decline, Neurocognitive disorder, Alzheimer's disease, vascular dementia, mixed dementia, Lewy body dementia, frontotemporal dementia, normal pressure hydrocephalus, medication side effect, depression, anxiety disorders, sleep disorders, substance use disorders, vitamin B12 deficiency, thyroid dysfunction, hypercalcemia, neurosyphilis, HIV-associated neurocognitive disorder, traumatic brain injury, brain tumors, seizure disorders, multiple sclerosis, Parkinson's disease, chronic liver disease, chronic kidney disease, electrolyte imbalances, heavy metal poisoning, alcohol-related brain damage, autoimmune encephalitis, post-concussion syndrome, long Covid
PLAN:
Investigations:
- Mini-mental state exam
- Blood work: , , , , , , , , , ,
- CT scan of the brain
- MRI of the brain
- Lumbar puncture
Treatments:
- 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
Further care:
- 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
HISTORY: Associated symptoms: EXAM: Neurologic: ASSESSMENT: PLAN: