History and Physical Examination

When obtaining the medical history, the physician should focus on the onset, trajectory, use of prescription and nonprescription drugs, history of substance abuse, vascular problems or risk factors (especially hypertension), history of head trauma, history of CNS infections or surgery, and family history of dementia. Assessment of ADLs and IADLs, whenever possible, should be demonstrated as part of the physical examination rather than rely on patient or family report. A general physical examination is appropriate to assess the status of comorbid conditions and for evidence of disease states that could be related to dementia. The cardiovascular examination is important to detect the presence of vascular disease. A careful neurologic exam, particularly to identify movement disorders and focal neurologic deficits, will impact the selection of diagnostic tests. ADL and IADL assessments often raise concerns about safety or potential for exploitation and may need to be followed up with a home visit or a referral to social services.

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