CGA

Past Medical History: - Hypertension - Type 2 Diabetes - Osteoarthritis - Atrial Fibrillation Medications: Lisinopril 20mg daily, Metformin 1000mg twice daily, Warfarin 2mg daily. Allergies: Penicillin - rash. Psychosocial History: Lives: with spouse in a single-story house Children: 2, Grandchildren: 4 Born in: London, UK Emigrated to Australia in: 1978 Personal Activities of Daily Living: Independent Domestic ADLs: Independent Community ADLs: Independent Current services in place: Home care assistance for cleaning and meal preparation. Driving: Drives regularly Falls in the last 12 months: 1, Mobility aid: Nil, Fall circumstances: Tripped on a rug at home. Educational level: Secondary school Employment History: Retired accountant. EPOA completed: Yes My Aged Care: Registered and receiving services. Nonsmoker, EtOH: Occasional social drinker, 1-2 standard drinks per week. Vaccinations: Up-to-date with flu, COVID-19, and pneumococcal vaccines. FHx: Father had a history of stroke. Exercise: Walks for 30 minutes, three times per week. Background: Mrs. Smith is a 82-year-old female referred for a comprehensive geriatric assessment due to concerns about increasing falls risk and memory changes. She reports a recent fall at home and subjective memory decline over the past six months. She is independent with most activities of daily living but requires some assistance with household chores. She is accompanied by her daughter, who is concerned about her mother's increasing forgetfulness and mobility issues. Assessments: Mini-Cog test performed, score of 3/5. Timed Up and Go test completed in 15 seconds. Blood pressure and pulse were taken in lying and standing positions. Systems Review: Appetite: Good Weight: Stable Mood: Appears mildly anxious. Sleeping: Sleeps 6-7 hours per night, occasionally disturbed by nocturia. Pain: Mild osteoarthritis pain in knees, managed with paracetamol. Aids used: Nil. Bowels: Regular. Bladder: Nocturia 2-3 times per night. Memory: Subjective memory decline reported by patient and daughter. Pathology: Full blood count, U&Es, LFTs, INR (results pending). O/E: Heart rate 78 bpm, blood pressure 130/80 mmHg lying, 120/70 mmHg standing, no postural drop. Neurological examination unremarkable. No peripheral oedema. Weight 70 kg. Gait slightly unsteady. Cognitive Assessment: Mini-Cog score of 3/5, indicating possible cognitive impairment. Further cognitive assessment recommended. Issues Discussed During Consultation: - Falls risk assessment and management: Discussed home safety modifications, balance exercises, and medication review. - Memory concerns: Discussed further cognitive assessment and potential causes. - Osteoarthritis management: Reviewed pain management strategies. - Medication review: Reviewed current medications and potential side effects. Plan / Recommendations: - Refer to a geriatrician for further cognitive assessment and management. - Recommend home safety assessment and modifications. - Encourage participation in a falls prevention program. - Review medications for potential side effects contributing to falls or cognitive decline. - Schedule a follow-up appointment in 3 months. Date: 1 November 2024