Thank you for referring this patient for assessment and consideration for our home-based primary care team. Intake visit was conducted on 1 November 2024, from 09:00 to 10:00.
Reason for Assessment:
- Cognitive decline and functional impairment.
- Collateral history was obtained from the patient's daughter.
History:
Patient is an 82-year-old female with a history of hypertension and mild cognitive impairment. She reports increasing difficulty with memory and managing her medications. She has been experiencing falls in the last 6 months.
Cognition:
- Cognitive domains affected: Short term memory, executive function.
- Short term memory issues: Patient struggles to recall recent events and appointments.
- Executive function: Difficulty with planning and problem-solving.
- Mood: Patient reports feeling sad and withdrawn, but denies suicidal ideation.
- Depression and anxiety screening results: GDS-15 score of 8, indicating mild depression.
- Sleep concerns: Patient reports difficulty falling asleep and staying asleep.
Falls/mobility:
- Dizziness with postural change: Yes, patient reports feeling lightheaded when standing up quickly.
- Falls: Yes, patient has fallen twice in the last 6 months, both resulting in minor injuries.
- Change in gait: Yes, patient's gait is slow and unsteady.
Medical History:
- Past medical history: Hypertension, mild cognitive impairment, osteoarthritis.
- Previous surgeries: Right hip replacement 5 years ago.
Functional Assessment:
- Activities of daily living (ADLs): Patient requires assistance with bathing and dressing.
- Instrumental activities of daily living (IADLs): Patient struggles with managing finances and medications.
- Mobility and gait: Slow and unsteady gait, uses a cane for ambulation.
- Use of assistive devices: Cane.
- Vision: Reports blurry vision.
- Hearing: Reports some hearing loss.
- Ability to leave the home: Limited due to mobility issues.
- Screening test results (e.g., MMSE, MoCA): MoCA score of 18.
Social History:
- Living situation: Lives alone in a single-family home.
- Support system: Daughter provides daily support.
- Occupation and retirement status: Retired teacher.
- Alcohol, tobacco, and substance use: Denies alcohol or tobacco use. No illicit substance use.
Other Geriatric Syndromes:
- Falls: Recurrent falls.
- Sleep issues: Insomnia.
ESAS:
- Pain, if mentioned: Mild pain in the right hip.
- Tiredness, if mentioned: Reports feeling tired most of the time.
- Depression, if mentioned: Reports feeling depressed.
Current Medications:
- Lisinopril 10mg daily
- Donepezil 5mg daily
Immunizations:
- Pneumococcal vaccine
- Influenza vaccine
Physical Examination:
- General appearance: Appears frail and elderly.
- Cardiovascular system: Regular rate and rhythm.
- Musculoskeletal system: Decreased range of motion in the right hip.
- Neurological examination: Mild cognitive impairment.
Investigations:
- Pertinent lab work: CBC, CMP, TSH, Vitamin D.
Impression:
Mild cognitive impairment with functional decline and recurrent falls.
Plan and Recommendations:
- Management plan: Referral to physical therapy for gait training and fall prevention. Medication review. Home safety assessment.
- Referrals to specialists or services: Physical therapy, occupational therapy.
- Donepezil: Continue.
- Goals of care: Maintain independence and prevent falls.
Follow-up:
Follow-up in 2 weeks.
Thank you for referring this patient for assessment and consideration for our home-based primary care team. Intake visit was conducted on [current date], from [exact start time] to [exact finish time].
Reason for Assessment:
- [Reason for referral or assessment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Collateral history was obtained from] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
History:
[Summarize the history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Cognition:
- [Cognitive domains affected] (Summarize if the following domains are affected: short term memory, speech and language, visual perceptual, praxis, divided attention, executive function) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Short term memory issues] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Speech and language issues] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Word finding issues] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Visual or perceptual disturbances] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Executive function] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Social skills] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Attention issues] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Mood] (Describe in detail) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Depression and anxiety screening results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Hallucinations] (Answer yes or no. Include details only if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Sleep concerns] (Answer yes or no and describe in detail) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Falls/mobility:
- [Dizziness with postural change] (Yes or no. If yes, describe in detail) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Tremor] (Answer yes or no. If yes, describe in detail) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Falls] (Answer yes or no. If yes, describe in detail) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Change in handwriting] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Change in gait] (Yes or no. If yes, describe in detail) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Injury] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Medical History:
- [Past medical history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Previous surgeries] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Functional Assessment:
- [Activities of daily living (ADLs)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Instrumental activities of daily living (IADLs)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Mobility and gait] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Use of assistive devices] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Vision] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Hearing] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Ability to leave the home] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Screening test results (e.g., MMSE, MoCA)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Social History:
- [Living situation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Support system] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Occupation and retirement status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Alcohol, tobacco, and substance use] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Other Geriatric Syndromes:
- [Falls] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Weight changes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Dietary intake] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Chronic pain issues] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Sleep issues] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
ESAS:
- [Pain, if mentioned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Dyspnea, if mentioned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Appetite, if mentioned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Nausea, if mentioned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Tiredness, if mentioned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Drowsiness, if mentioned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Depression, if mentioned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Anxiety, if mentioned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Wellbeing, if mentioned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Bowel function, if mentioned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Bladder function, if mentioned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Current Medications:
- [List medications and dose] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- See profile for full medication list
Immunizations:
- [List of immunizations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Physical Examination:
- [Vital signs] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [General appearance] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Cardiovascular system] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Respiratory system] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Abdominal examination] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Musculoskeletal system] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Neurological examination] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Investigations:
- [Neuroimaging] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Pertinent lab work] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Impression:
[Write an impression] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Plan and Recommendations:
- [Management plan] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Referrals to specialists or services] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Donepezil] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [DNR] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Goals of care] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Follow-up:
(Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)
