VVED RACF General Consultation (GEDI)

General Examination and Diagnostic Information (GEDI) Patient Information: - John Doe - 78 - Male - 123456 Chief Complaint: - Shortness of breath and chest pain History of Present Illness: - The patient has been experiencing shortness of breath and chest pain for the past 2 days. Symptoms began suddenly and have been progressively worsening. No previous interventions have been attempted. Past Medical History: - Hypertension, Type 2 Diabetes, Coronary Artery Disease Medications: - Metformin 500mg twice daily, Lisinopril 10mg daily, Aspirin 81mg daily Allergies: - Penicillin (rash) Social History: - Lives in a residential aged care facility, non-smoker, occasional alcohol use Family History: - Father had a history of heart disease Review of Systems: - Cardiovascular: Reports chest pain, denies palpitations - Respiratory: Reports shortness of breath, denies cough Physical Examination: - General Appearance: Alert, in mild distress - Vital Signs: BP 150/90, HR 88, RR 22, Temp 37.2°C, SpO2 92% on room air - HEENT: No abnormalities noted - Cardiovascular: Regular rhythm, no murmurs - Respiratory: Decreased breath sounds in the right lower lobe - Abdominal: Soft, non-tender - Musculoskeletal: No joint swelling or tenderness - Neurological: Alert and oriented Diagnostic Tests: - Chest X-ray: Right lower lobe consolidation - ECG: Normal sinus rhythm Assessment: - Suspected pneumonia with possible exacerbation of coronary artery disease Plan: - Initiate antibiotics for pneumonia - Monitor cardiac status closely - Follow-up with GP in 3 days VVED RACF General Consultation Confirm 3 points of ID: John Doe, 01/01/1945, Medicare Number: 987654321 RACF Nurse Name: Jane Smith Substitute Medical Decision Maker/Next of Kin: Mary Doe Advanced Care Directive: Comfort measures only GP Details: Dr. Sarah Brown, ABC Medical Clinic Residential In-Reach Team: Team A, contact number 555-1234 Presenting Complaint: - Shortness of breath and chest pain History of Presenting Complaint: - The patient has been experiencing shortness of breath and chest pain for the past 2 days. Symptoms began suddenly and have been progressively worsening. No previous interventions have been attempted. Past Medical History: - Hypertension, Type 2 Diabetes, Coronary Artery Disease Medications: - Metformin 500mg twice daily, Lisinopril 10mg daily, Aspirin 81mg daily Allergies: - Penicillin (rash) Baseline: Cognition: Alert and oriented Mobility: Ambulates with a walker Continence: Continent Ability to Self-Care: Requires assistance with bathing and dressing Objective: Observations: BP 150/90, HR 88, RR 22, Temp 37.2°C, SpO2 92% on room air Impression: - Suspected pneumonia with possible exacerbation of coronary artery disease Discussion with MTDM/NOK: - Discussed the current condition and management plan with Mary Doe, who agreed with the proposed interventions. Management Plan: • Initiate antibiotics for pneumonia • Monitor cardiac status closely • Recommended follow-up with GP in 3 days • A copy of the clinical consult notes have been sent to the RACF on the registered email address.