behavioral_clinic_template.md 3.07 KB
behavioral neurology oupatient clinic template v1

HPI

name:
age:
handedness:
CC referral:
CC patient:

symptom onset:
course (progressive?):
additional HPI:

 
 
 
 
   

ROS

  • memory
    misplacing things? change?
    disorientation? repeated questions?
    finances: doing now? previously did?
    stove-on/water-running: driving (yes/no, accidents, lost):

  • other cognitive function
    confusion
    language-dysfunction
    apraxia
    visuospatial

  • sleep
    acting-out-dreams
    insomnia

  • gait
    falls       near-falls       imbalance changes

  • autonomic symptoms
    dizziness/lightheaded/orthostasis       syncope       bowel/bladder-problems/changes       fevers/chills/sweats palpitations

  • ADLs
    finances       cooking       toileting

  • alt-neuro
    weakness       numbness/tingling

  • psych
    mood:
    depressed       anxious       hallucinations
    stressors:

PMHx

stroke       migraine       seizure head-trauma       meningitis       HTN       DM       HLD       a-fib/heart-dz

 
 
 
 

meds

 
 
 
 

SHx

EtOH:
tobacco:
illicit drugs:
occupation:
married/prior-marriages:
living location/situation:

FHx

dementia:
dad:
mom:
siblings:
children:

Exam

MMSE:

CV:
Resp:
Ophtho:

Neuro:
MS:
CN:
Mot:
Sens:
Refl:
Coord:
Gait:

Labs/Studies

MRI:
neuropsych:
LP:

Impression

Formulation:
[age] year-old [R/L]-handed [man/woman] presents with [chief complaint]. Exam notable for [notable exam elements]. Studies notable for [notable studies]. Localization includes: [localization differential if applicable from cortex to muscle vs. e.g. diffuse].

Differential includes:

  • dementia: cognitive complaint of sufficient severity to compromise daily functioning
  • MCI: cognitive complaint, abnormal for age, cognitive decline/change, essentially normal functional/day-to-day activities
    • if MCI/dementia: amnestic or non-amnestic?
  • neurodegenerative: slow/gradual course
    • alzheimer's: can include atypical presentations affecting attention, concentration, and language
    • dementia with lewy bodies: attention, concentration, visuospatial difficulty
    • frontotemporal dementia: behavioral changes with inappropriateness, apathy, lack of insight, & attentional/concentration difficulty
  • vascular: risk factors? acute changes possible
  • psychiatric: depression/anxiety?
  • general medical: CHF, DM, COPD

Plan

neuropsych       MR-brain       CT-head       brain-tips sheet

labs: CBC       renal       CBC S-TSH B12       thiamine       RPR

rtnv (time frame?)?

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