Daughter first notices repeated questions.
informant form p.2
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History of Presenting Problem
Mr. Doe is a 72-year-old retired accountant referred by his primary care physician for evaluation of memory decline. He reports misplacing items and repeating questions over the past 18 months, which his daughter first noticed in 2023. A brain MRI showed mild generalized atrophy, and he scored 23/30 on the MoCA, losing most points on delayed recall.
He described getting lost driving to a familiar store and endorsed low mood since retirement, with a PHQ-9 total of 9.
Source documentChronology5 entries · 5 sourcesReferral order · primary carep. 1 of 2Clinical interview · transcript04:12Informant questionnaire · daughterp. 2 of 4MRI brain without contrastp. 1 of 2MoCA · cognitive screen01/14/2025 · 23/30Clinical interview · transcript11:47PHQ-9 · patient self-report05/02/2025
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HISTORY OF PRESENTING PROBLEM — CHRONOLOGY
2023
01/14/25
PCP visit; MoCA 23/30, delayed recall 1/5.
MoCA p.1
03/05/25
MRI brain: mild generalized volume loss.
MRI brain p.1
04/02/25
Referred for neuropsychological evaluation.
referral order p.1
05/02/25
Clinical interview; 18 months of memory change.
interview 04:12
REFERRAL FOR NEUROPSYCHOLOGICAL EVALUATION
Date
04/02/2025
Referring provider
R. Sample, MD · Internal Medicine
Reason for referral
Progressive memory complaints; please evaluate for neurocognitive disorder.
Relevant history
Hypertension, hyperlipidemia. MoCA 23/30 on 01/14/2025.
Questions
Diagnosis, severity, driving safety, recommendations
CLINICAL INTERVIEW — 05/02/2025
03:58
ClinicianWhat made you decide to come in now?
04:12
PatientI keep misplacing things, my keys, my glasses. And my daughter says I ask the same questions. It's been about a year and a half.
04:40
ClinicianHas anything changed with driving or getting around?
11:47
PatientLast spring I got turned around driving to the hardware store. I've gone there for twenty years.
12:10
ClinicianHow has your mood been since you retired?
12:18
PatientFlatter, I'd say. Less interested in things.
CLINICAL INTERVIEW — 05/02/2025
03:58
ClinicianWhat made you decide to come in now?
04:12
PatientI keep misplacing things, my keys, my glasses. And my daughter says I ask the same questions. It's been about a year and a half.
04:40
ClinicianHas anything changed with driving or getting around?
11:47
PatientLast spring I got turned around driving to the hardware store. I've gone there for twenty years.
12:10
ClinicianHow has your mood been since you retired?
12:18
PatientFlatter, I'd say. Less interested in things.
INFORMANT QUESTIONNAIRE — COMPLETED BY DAUGHTER
Relationship to patient
Daughter
How often do you see the patient?
3–4 times a week
When did you first notice changes?
Around spring 2023, asking the same things twice
Biggest concern right now
Driving + remembering his meds
Changes observed (check all that apply)
Repeats questionsMisplaces itemsGets lostWord-findingPersonality changeMood change
IMAGING CENTER — MRI BRAIN WITHOUT CONTRAST
Exam date
03/05/2025
Indication
Memory loss
Findings
No acute infarct, hemorrhage, or mass. Scattered mild periventricular white matter changes.
Impression
Mild generalized volume loss, slightly greater than expected for age.
Comparison
None available
COGNITIVE SCREENING · FORM B
Name Mr. DoeEducation 16Date 1/14/25
Visuospatial / Executive
4/5
Naming
3/3
Memory
Read list; patient repeats. Two trials. Recall after 5 minutes.
RIVERCANDLEGARDENBUTTONPURPLETrial 1✓✓✓Trial 2✓✓✓✓
No pts
Attention
Forward 3 1 7 9 4 ✓ Backward 5 8 2 ✓
Serial 7s from 100 93 86 79 72 66
5/6
Language
Repeat two sentences ✓ ✗ Fluency, 1 min 12 words ✓
2/3
Abstraction
Similarity: shirt – sock clothes ✓ piano – drum instruments ✓
2/2
Delayed recall
RIVERCANDLEGARDENBUTTONPURPLEFree recall✓
1/5
Orientation
Date ✓Month ✓Year ✓Day ✓Place ✓City ✓
6/6
Mock form for illustration. Add 1 point if ≤ 12 yrs education.Total 23/30
PHQ-9 — SCORE SUMMARY
Completed 05/02/2025Respondent Patient
| Domain | Score |
|---|---|
| Little interest or pleasure | 2 / 3 |
| Feeling down | 1 / 3 |
| Sleep | 2 / 3 |
| Tired / low energy | 2 / 3 |
| Appetite | 0 / 3 |
| Feeling bad about yourself | 1 / 3 |
| Concentration | 1 / 3 |
| Total | 9 / 27 |
Items 8–9 scored 0. Total 5–9 = mild.
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