Scribe BC - Falls template

Identification: Mrs. Eleanor Vance, [age 82], presents today for a comprehensive geriatric assessment with a focus on falls prevention. She reports a history of falls, including two falls in the past six months, both occurring at home. She is accompanied by her daughter, Sarah. History of Presenting Illness: Mrs. Vance reports experiencing dizziness and unsteadiness, particularly when standing up from a seated position. She describes this as orthostatic hypotension. She also notes a recent increase in muscle weakness in her legs, making it difficult to navigate stairs. She denies any loss of consciousness or head trauma associated with her falls. She also reports some mild neuropathy in her feet, which she believes contributes to her balance issues. Past Medical History: * Hypertension * Osteoarthritis * Type 2 Diabetes * Previous myocardial infarction Allergy: Mrs. Vance has no known allergies. Medication: * Lisinopril 10mg daily * Metformin 500mg twice daily * Aspirin 81mg daily * Bisoprolol 2.5mg daily Social History: Mrs. Vance is a retired teacher. She lives independently in her own home. She does not smoke and drinks alcohol occasionally. She denies any history of drug use. Functional Review: Mrs. Vance reports some difficulty with instrumental activities of daily living (IADLs), such as managing finances and preparing meals. She is independent with activities of daily living (ADLs), including bathing, dressing, and toileting. Physical Examination: General Exam: Blood pressure seated 130/80 mmHg, standing 110/70 mmHg, heart rate seated 72 bpm, standing 78 bpm, height 5'4", weight 145 lbs. Falls Specific Assessment: Calculated falls risk score is high. Contributing deficits include core and hip strength weakness, impaired proprioception. Timed Up and Go score is 18 seconds. Gait speed is reduced. She is unable to hold tandem stance for more than 3 seconds. Cognitive Screen: MMSE score 28/30, MoCA score 24/30. Mood screening questionnaire: Geriatric Depression Scale score 3/15. Investigations: Vitamin D level pending. Assessment and Plan: 1. Falls Risk: Mrs. Vance is at high risk for falls due to orthostatic hypotension, muscle weakness, impaired balance, and a history of falls. Contributing factors include sarcopenia and polypharmacy. Recommended baseline blood work includes a Vitamin D level. Suggested targeted exercises include balance training and lower extremity strengthening exercises. Patient will be provided with handouts on fall prevention and information for Physio for Seniors. Patient plans to start physiotherapy next week. Discussed low blood pressure/heart rate, orthostasis, and medication adjustments. Bisoprolol will be reviewed and potentially adjusted. Rationale for medication review is to address potential contributors to orthostatic hypotension. 2. Follow up: Follow-up appointment scheduled in 3 months to reassess falls risk and review progress. "This document was created using AI Ambient Scribe and Front-End Speech Recognition software and may include incorrect spelling/words. Consent for usage of AI was obtained by patient/guardian."