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Assessment:
The patient presents with progressive memory loss, difficulty with daily tasks, and changes in cognition, consistent with dementia. There are no signs of acute delirium or reversible causes. Differential diagnosis includes Alzheimer’s disease, vascular dementia, Lewy body dementia, and frontotemporal dementia, normal aging.
Plan:
Order a cognitive screening test (e.g., MMSE or MoCA) to assess severity. Labs should include TSH, B12, and CMP to rule out reversible causes such as thyroid dysfunction or vitamin deficiency. Consider neuroimaging (CT or MRI) to evaluate for structural brain changes. Educate the patient and family about the progressive nature of dementia and the importance of safety measures (e.g., fall prevention, medication management). Start cholinesterase inhibitors (e.g., donepezil) if Alzheimer’s is suspected, or refer to neurology for further evaluation and management. Schedule follow-up visits every 3-6 months to monitor progression and reassess care needs. Refer to social work or support groups for caregiver assistance.
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