Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
Chief Complaint: Briefly describe the patient’s main reason for this visit. This could include:
Worsening of movement symptoms (chorea, rigidity, bradykinesia)
Cognitive decline (memory problems, difficulty concentrating)
Mood changes (irritability, depression, anxiety)
Difficulty with activities of daily living (ADLs)
Family member or caregiver concerns
History of Present Illness:
Progression of symptoms since last visit
Impact of symptoms on daily life (work, hobbies, self-care)
Changes in medication regimen and response
Hospitalizations or falls (if applicable)
Past Medical History:
Age at symptom onset
Confirmation of Huntington’s disease diagnosis (genetic testing or family history)
Family history of Huntington’s disease
Prior hospitalizations or surgeries
Current medications (including those for movement disorders, mood, or cognition)
Psychiatric history (depression, anxiety)
Family History:
Presence of Huntington’s disease in first-degree relatives
Age at onset in family members (if known)
Social History:
Occupation (current or past, impact of disease on work)
Living situation (alone, with family, support system)
Alcohol or substance use history
Physical Examination:
General appearance (gait, posture, facial expressions)
Neurological exam:
Movement: chorea (involuntary jerky movements), rigidity, bradykinesia (slowness of movement)
Coordination and balance
Eye movements
Speech and language
Cognitive testing (brief bedside assessment)
Mental status exam (mood, affect, cognition)
Laboratory Tests:
Genetic testing for Huntington’s disease (confirmatory testing, not routinely done at every visit)
Thyroid function tests (can mimic some symptoms)
Vitamin deficiencies (B12 deficiency can cause movement disorders)
Imaging Studies:
Brain imaging (MRI scan) – not routinely done for established diagnosis but may be helpful to rule out other causes of symptoms.
Diagnosis:
Huntington’s disease (confirmed or suspected)
Stage of Huntington’s disease (early, mid, late) based on symptom severity and functional limitations
Treatment Plan:
Medications to manage movement symptoms (dopamine agonists, tetrabenazine) – effectiveness may decline over time
Cognitive rehabilitation therapy
Speech therapy (if speech affected)
Physical therapy and occupational therapy to maintain function and independence
Mental health support (antidepressants, psychotherapy) for mood and anxiety
Social work and caregiver support services
Prognosis:
Discuss the progressive nature of the disease and expected course
Importance of ongoing supportive care and management of symptoms
Patient Education and Caregiver Support:
Disease education (progression, treatment options)
Importance of medication adherence
Safety precautions to prevent falls and injuries
Strategies for coping with cognitive decline and emotional changes
Referral to support groups and resources for patients and caregivers
Next Follow-up:
Schedule for the next appointment to monitor symptom progression, adjust medications as needed, and address any new concerns.
Discuss the importance of regular follow-up and communication with the healthcare team.