Cognitive exam

Date of consult
[date name="variable_3" default="today"]

History of Presenting Illness -[textarea name="variable5" default=""]

Allergies -[textarea name="allergies_1" default="No Known Allergies"]
Past Surgical History -[textarea name="Surgery_text" default="Non contributory"]

Family History -[textarea name="family_text" default=""]

Social History -[textarea name="Social1text" default=""]

Safety Evaluation of Home and Motor Vehicle Operation -[textarea name="Social2text" default=""]

[checkbox name="Social1" value="Patient has adequate caregivers at home| Patient lives in a LTC facility| caregivers were present and I have educated the caregivers on how to adequately care for the patient| Patients caregivers were not present. I will supply them with instruction on caring for the patient upon discharge|"][conditional field="Social1" condition="(Social1).is('')"][textarea name="Socialtxt1" default=""][/conditional]


Medication -
[select name="Med1" value="I have reviewed the patient's medications|"][conditional field="Med1" condition="(Med1).is('')"][textarea name="Medtxt1" default=""][/conditional]

Review of Systems
[comment memo="Default will be negative. Click if positive"]
General
[checklist name="ROS1" value="Sleep Disturbances|Fatigue|Skin Changes|Recent Falls|Unable to asses/patient nonverbal"]
[conditional field="ROS1" condition="(ROS1).is('Recent Falls')"]
[textarea name="ROStext1" default=""][/conditional]
Neurological
[checklist name="ROS2" value="Syncope|Headache|Coordination Changes|Weakness| Numbness|Unable to asses/patient nonverbal"]
HEENT
[checklist name="ROS3" value="Vision Changes|Eye Pain|Nasal Congestion|Nasal Discharge|Hearing Changes|Pain in Ear|Dysphagia|Odynophagia|Unable to asses/patient nonverbal"]
Cardiovascular
[checklist name="ROS4" value="Chest Pain|Palpitations|Unable to asses/patient nonverbal"]
Respiratory
[checklist name="ROS5" value="Dyspnea|Cough|Shortness of Breath|Unable to asses/patient nonverbal"]
Gastrointestinal
[checklist name="ROS6" value="Nausea|Vomiting|Diarrhea|Constipation|Abdominal Pain|Unable to asses/patient nonverbal"]
Genitourinary
[checklist name="ROS7" value="Urinary incontinence|Dysuria|Unable to asses/patient nonverbal"]
Musculoskeletal
[checklist name="ROS14" value="Upper extremity weakness|Lower extremity Weakness|Back Pain|Muscle Pain|Generalized weakness|Difficulty walking|Joint pain in knees|Joint pain in hips|Unable to asses/patient nonverbal"]
Hematology and Lymph Nodes
[checklist name="ROS8" value="Bleeding|Bruising|Palpable Lymph Nodes|Unable to asses/patient nonverbal"][conditional field="ROS8" condition="(ROS8).is('Bleeding')"]
[textarea name="ROStext8" default=""][/conditional][conditional field="ROS8" condition="(ROS8).is('Bruising')"]
[textarea name="ROStext9" default=""][/conditional][conditional field="ROS8" condition="(ROS8).is('Palpable Lymph Nodes')"]
[textarea name="ROStext10" default=""][/conditional]
Endocrinology
[checklist name="ROS11" value="Thirst|Weight Gain|Weight Loss|Frequent Urination|Unable to asses/patient nonverbal"]
Psychiatric
[checklist name="ROS12" value="Anxiety|Depression|Suicidal Ideation|Homicidal Ideation|Mood Changes|Unable to asses/patient nonverbal"]
[textarea name="ROStext13" default=""]

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Barthel Index of Activities of Daily Living

[select name="bowels" value="0|1|2"] <-- Bowels
0 = incontinent (or needs to be given enemas)
1 = occasional accident (once/week)
2 = continent

[select name="bladder" value="0|1|2"] <-- Bladder
0 = incontinent, or catheterized and unable to manage
1 = occasional accident (max. once per 24 hours)
2 = continent (for over 7 days)

[select name="grooming" value="0|1"] <-- Grooming
0 = needs help with personal care
1 = independent face/hair/teeth/shaving (implements provided)

[select name="toilet" value="0|1|2"] <-- Toilet use
0 = dependent
1 = needs some help, but can do something alone
2 = independent (on and off, dressing, wiping)

[select name="feeding" value="0|1|2"] <-- Feeding
0 = unable
1 = needs help cutting, spreading butter, etc.
2 = independent (food provided within reach)

[select name="transfer" value="0|1|2|3"] <-- Transfer
0 = unable – no sitting balance
1 = major help (one or two people, physical), can sit
2 = minor help (verbal or physical)
3 = independent

[select name="mobility" value="0|1|2|3"] <-- Mobility
0 = immobile
1 = wheelchair independent, including corners, etc.
2 = walks with help of one person (verbal or physical)
3 = independent (but may use any aid, e.g., stick)

[select name="dressing" value="0|1|2"] <-- Dressing
0 = dependent
1 = needs help, but can do about half unaided
2 = independent (including buttons, zips, laces, etc.)

[select name="stairs" value="0|1|2"] <-- Stairs
0 = unable
1 = needs help (verbal, physical, carrying aid)
2 = independent up and down

[select name="bathing" value="0|1"] <-- Bathing
0 = dependent
1 = independent (or in shower)

Total Score --> [calc memo="number" value="score1=(bowels)+(bladder)+(grooming)+(toilet)+(feeding)+(transfer)+(mobility)+(dressing)+(stairs)+(bathing)"] / 20
Interpretation Lower scores indicate increased disability. If used to measure improvement after rehabilitation, changes of more than two points in the total score reflect a probable genuine change, and change on one item from fully dependent to independent is also likely to be reliable.
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Depression Screening 

[select name="Q1" value="not at all (0 points)=0|several days (1 point)=1|more than half the days (2 points)=2|nearly every day (3 points)=3"] Little interest or pleasure in doing things over the last 2 weeks
[select name="Q2" value="not at all (0 points)=0|several days (1 point)=1|more than half the days (2 points)=2|nearly every day (3 points)=3"] Feeling down, depressed or hopeless over the last 2 weeks
[select name="Q3" value="not at all (0 points)=0|several days (1 point)=1|more than half the days (2 points)=2|nearly every day (3 points)=3"] Trouble falling or staying asleep, or sleeping too much over the last weeks
[select name="Q4" value="not at all (0 points)=0|several days (1 point)=1|more than half the days (2 points)=2|nearly every day (3 points)=3"] Feeling tired or having little energy over the last 2 weeks
[select name="Q5" value="not at all (0 points)=0|several days (1 point)=1|more than half the days (2 points)=2|nearly every day (3 points)=3"] Poor appetite or overeating over the last 2 weeks
[select name="Q6" value="not at all (0 points)=0|several days (1 point)=1|more than half the days (2 points)=2|nearly every day (3 points)=3"] Feeling bad about self-or are a failure or have let self or family down over the last 2 weeks
[select name="Q7" value="not at all (0 points)=0|several days (1 point)=1|more than half the days (2 points)=2|nearly every day (3 points)=3"] Trouble concentrating on things, such as reading the newspaper or watching television over the last 2 weeks
[select name="Q8" value="not at all (0 points)=0|several days (1 point)=1|more than half the days (2 points)=2|nearly every day (3 points)=3"] Moving or speaking so slowly that other people have noticed. Or the opposite-being so fidgety or restless that has been moving around a lot more than usual over the last 2 weeks
[select name="Q9" value="not at all (0 points)=0|several days (1 point)=1|more than half the days (2 points)=2|nearly every day (3 points)=3"] Thoughts that would be better off dead or of hurting self in some way over the last 2 weeks
Score --> [calc value="score=(Q1)+(Q2)+(Q3)+(Q4)+(Q5)+(Q6)+(Q7)+(Q8)+(Q9)" memo="score"] out of 27 points. Interpretation --> [calc value="score=(Q1)+(Q2)+(Q3)+(Q4)+(Q5)+(Q6)+(Q7)+(Q8)+(Q9);score>20?'Severe':score>14?'Moderately Severe':score>9?'Mild':score>4?'Minimal Symptoms':'Asymptomatic'" memo="interpretation"]
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Physical Exam [comment memo="Please write in Vitals"]
Vital Signs - [textarea name="VS1" default="BP- mmgHg T- °F P- beats/min R- breaths/min"]
General - [textarea name="Pe1" default="No acute distress, Well developed, well-nourished, Afebrile"]
Neurological - [textarea name="Pe2" default="Alert and Oriented, Normal mood and affect, Cranial Nerves II-XII grossly intact"]
HEENT - [textarea name="Pe3" default="Head is normocephalic, atraumatic. Bilateral pupils are equal and reactive to light and accommodating. No scleral icterus, no conjunctival pallor. No neck masses were palpated."]
Pulmonary - [textarea name="Pe4" default="Respiratory effort within normal limits."]
Cardiovascular - [textarea name="Pe5" default="Distal pulses 2+ in all extremities. Adequate perfusion. No peripheral signs of cyanosis."]
Gastrointestinal - [textarea name="Pe6" default="Abdomen soft, nontender, nondistended. No guarding or tenderness."]
Musculoskeletal - [textarea name="Mskphys" default="No visible deformities. No pain on palpation over upper extremities, lower extremities, chest, and back.  No pain or limitations in passive range of motion in all 4 extremities.  Strength 5/5 in all 4 extremities.  "]

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Saint Louis University Mental Status (SLUMS) Examination
1. [select name="DayOfWeek" value="Correct (1 point)=1|Incorrect (0 points)=0"] <-- What day of the week is it?
2. [select name="Year" value="Correct (1 point)=1|Incorrect (0 points)=0"] <-- What is the year?
3. [select name="State" value="Correct (1 point)=1|Incorrect (0 points)=0"] <-- What state are we in?
4. Please remember these five objects. I will ask you what they are later: apple, pen, tie, house, car.
5. You have $100 and you go to the store and buy a dozen apples for $3 and a tricycle for $20.
   [select name="Spend" value="Correct (1 point)=1|Incorrect (0 points)=0"] <-- How much did you spend?
   [select name="Left" value="Correct (2 points)=2|Incorrect (0 points)=0"] <-- How much do you have left?
6. [select name="Animals" value="0-4 animals (0 points)=0|5-9 animals (1 point)=1|10-14 animals (2 points)=2|15+ animals (3 points)=3"] <-- Please name as many animals as you can in one minute.
7. [select name="Objects" value="1 object (1 point)=1|2 objects (2 points)=2|3 objects (3 points)=3|4 objects (4 points)=4|5 objects (5 points)=5"] <-- What were the five objects I asked you to remember?
8. I am going to say a series of numbers and I would like you to give them to me backwards. For example, if I say 42, you would say 24.
   [select name="Backwards1" value="No points"] <-- 87
   [select name="Backwards2" value="Correct (1 point)=1|Incorrect (0 points)=0"] <-- 649
   [select name="Backwards3" value="Correct (1 point)=1|Incorrect (0 points)=0"] <-- 8537
9. (Draw circle.) This circle represents a clock face. Please put in the hour markers and the time at ten minutes to eleven o'clock.
   [select name="Hour" value="Correct (2 points)=2|Incorrect (0 points)=0"] <-- Hour marker correct?
   [select name="Time" value="Correct (2 points)=2|Incorrect (0 points)=0"] <-- Correct time?
10. (Show a triangle, a square and a rectangle.) 
   [select name="XTriangle" value="Correct (1 point)=1|Incorrect (0 points)=0"] <-- Please place an X in the triangle.
   [select name="Largest" value="Correct (1 point)=1|Incorrect (0 points)=0"] <-- Which of those objects is the largest?
11. I am going to tell you a story. Please listen carefully because afterward, I'm going to ask you some questions about it.
"Jill was a very successful stockbroker. She made a lot of money in the stock market. She then met Jack, a devastatingly handsome man. She married him and had three children. They lived in Chicago. She then stopped working and stayed at home to bring up her children. When they were teenagers, she went back to work. She and Jack lived happily ever after.  "
   [select name="FemaleName" value="Correct (2 points)=2|Incorrect (0 points)=0"] <-- What was the female's name?
   [select name="BackToWork" value="Correct (2 points)=2|Incorrect (0 points)=0"] <-- When did she go back to work?
   [select name="WorkDone" value="Correct (2 points)=2|Incorrect (0 points)=0"] <-- What work did she do?
   [select name="WhatState" value="Correct (2 points)=2|Incorrect (0 points)=0"] <-- What state did she live in?
12. [select name="Education" value="High School or above|Less than High School"] <-- Education?
SCORE:  [conditional field="Education" condition="(Education).is('High School or above')"][calc value="score=(WhatState)+(WorkDone)+(BackToWork)+(FemaleName)+(Largest)+(XTriangle)+(Time)+(Hour)+(Backwards2)+(Backwards3)+(Objects)+(Animals)+(Left)+(Spend)+(State)+(Year)+(DayOfWeek)" memo="score"]/30  [calc value="score=(WhatState)+(WorkDone)+(BackToWork)+(FemaleName)+(Largest)+(XTriangle)+(Time)+(Hour)+(Backwards2)+(Backwards3)+(Objects)+(Animals)+(Left)+(Spend)+(State)+(Year)+(DayOfWeek);score>26?'Normal':score>20?'Mild neurocognitive disorder':'Dementia'" memo="interpretation"][/conditional][conditional field="Education" condition="(Education).is('Less than High School')"][calc value="score=(WhatState)+(WorkDone)+(BackToWork)+(FemaleName)+(Largest)+(XTriangle)+(Time)+(Hour)+(Backwards2)+(Backwards3)+(Objects)+(Animals)+(Left)+(Spend)+(State)+(Year)+(DayOfWeek)" memo="score"]/30  [calc value="score=(WhatState)+(WorkDone)+(BackToWork)+(FemaleName)+(Largest)+(XTriangle)+(Time)+(Hour)+(Backwards2)+(Backwards3)+(Objects)+(Animals)+(Left)+(Spend)+(State)+(Year)+(DayOfWeek);score>24?'Normal':score>19?'Mild neurocognitive disorder':'Dementia'" memo="interpretation"][/conditional]  
[comment memo="note:  maximum score is 30.  27 and above is normal for high school educated adults.  25 and above is normal for those with less education."]
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Diagnostic Studies
[checkbox name="dx_1" value="I have reviewed this patient's lab result|No current labs at this time|I have reviewed this patients diagnostic imaging|No diagnostic imaging at this time|"]
[conditional field="dx_1" condition="(dx_1).is('')"][textarea name="dxtxt1" default=""][/conditional]

Advance Care Planning
[select name="ACP1" value="This patient has advanced care directives|This patient does not have previously established advanced care directives"]
[conditional field="ACP1" condition="(ACP1).is('This patient has advanced care directives')"][checkbox name="ACP" value="Do Not Resuscitate|Do Not Intubate|POLST|MOLST"][/conditional][conditional field="ACP1" condition="(ACP1).is('This patient does not have previously established advanced care directives')"][textarea name="ACPtxt" default=""][/conditional]
[textarea name="ACPtxt2" default=""]

Assessment
[comment memo="Be sure to mention Neuropsychiatric symptoms, Neurocognitive symptoms, Functional Limitations"]
[textarea name="Ass1" default=""]

Plan 
[comment memo="Be sure to mention referrals to community services such as rehab, adult day programs, support groups, etc; shared planning and education with patient and/or caregiver"]
[textarea name="Plan1" default=""]