Nicola Lodge Follow-up

"The patient/family provided verbal consent to use the AI scribe during this visit, understanding its purpose, potential benefits, and limitations, as well as the need for a temporary audio recording for documentation and associated privacy and security risks." **IDENTIFYING DATA** Mr. John Smith, [insert age] 82-year-old male, residing in a long-term care facility. He is widowed and retired. His financial situation is stable, supported by a pension and savings. **Referral source:** Dr. Emily Carter, Family Physician. PHN: 123-456-789 **INTERIM HISTORY** Patient presents with increased confusion and agitation over the past week. He reports difficulty remembering recent events and struggles with word-finding. He denies any new physical symptoms. His mood appears labile, with periods of both sadness and irritability. Sleep patterns are disrupted, with frequent nighttime awakenings. Eating habits are unchanged. No recent medication changes. No new side effects reported. **COLLATERAL INFORMATION: ** Mrs. Jane Doe, daughter, reports increased confusion and agitation, especially in the evenings. She notes he has been wandering more frequently and has become more resistant to care. Mr. Robert Green, Nurse, reports increased confusion and agitation, especially in the evenings. He notes he has been wandering more frequently and has become more resistant to care. **CURRENT MEDICATIONS** - Donepezil 10mg daily, for Alzheimer's disease. - Sertraline 50mg daily, for depression. - Lorazepam 0.5mg as needed for anxiety. **Mental Status Examination: ** Appearance: The patient is well-groomed and appropriately dressed. He appears his stated age. Behavior: The patient is restless and agitated, pacing during the interview. He is cooperative but easily distracted. Speech: Speech is clear but slow, with occasional word-finding difficulties. The patient is coherent. Mood: The patient reports feeling sad and frustrated with his memory loss. Affect: Affect is congruent with mood, with periods of tearfulness and irritability. Thoughts: The patient denies any suicidal ideation, homicidal ideation, or delusions. He expresses concern about his memory. Perceptions: patient was not observed to be attending to internal stimuli and denied any auditory or visual hallucinations. Cognition: The patient is oriented to person but not to time or place. He has significant deficits in recent and remote memory. Concentration is impaired. He is able to follow simple commands. Insight: The patient acknowledges his memory problems but does not fully understand the extent of his cognitive impairment. Judgment: Judgment is impaired due to cognitive deficits. **INVESTIGATIONS** No new investigations reviewed since the last follow-up. **IMPRESSION** 82-year-old male with a history of Alzheimer's disease, presenting with increased confusion, agitation, and functional decline. He exhibits temporal disorientation, repetitive questioning, and recent recall deficits. He uses a walker for mobility and is at risk for falls. He is oriented to person but not to time or place. His mood is labile, and he has no other symptoms. He receives support from family and staff, with safety measures in place. **Plan: (Always ensure that under each subheading below it is filled with bullet points, If a subheading below is omitted re-number the subsequent subheading sections)** **1. Certification** No certification is indicated at this time. **2. Safety** • The patient is at risk for falls due to his cognitive impairment and mobility issues. The facility is implementing fall prevention strategies. • There is no current suicidal or homicidal ideation. • Aggression Verbal / Physical: Please continue regular ABC assessments following behavioural events so that a comprehensive behavioural plan can be developed for his care management. The detailed documentation as obtained is extremely helpful in helping delineate and identify strategies that can be discussed. -→Suggest team debriefs and re-evaluation of PIECES care huddles following any physical aggression events. **3. Biological (including Medications)** • Continue Donepezil 10mg daily. • Continue Sertraline 50mg daily. • Consider increasing Lorazepam to 1mg as needed for agitation. • I have reviewed today with family’s the risk and benefits of initiating an antipsychotic in the context of a known major neurocognitive disorder. Including the black box warning for increased cerebrovascular and all cause mortality. Family agree that at this point the benefits outweigh the risk. I have also reviewed other common side effects. **4. Share-care/ Investigations** • A number investigations should be monitored on a regular basis given the plan at this time to use of psychotropic agents. We will ask family physician to assist this this. • We will recommend monitoring of: CBC Electrolytes, BUN, Creatinine, TSH, INR, PTT, AST, ALT, GGT, Alk Phos, Bilirubin, VIt B12, Folate, HgB A1C, lipid panel, and EKG on a routine basis. **5. Neurostimulation** Not indicated at this time. **6. Psychosocial** • I encouraged the facility to continue to have regular in open cleared dialogue with the family to provide education on the BPSD symptoms as observed. • Writer has reviewed with staff the importance of ensuring consistent but flexible care approach. **7. Follow-up** • Follow-up will be organized and arranged with the director of care "It has been a pleasure being a part of the care for this patient. If there are any questions, please do not hesitate to contact me. " Dr. Thomas Kelly "Geriatric Psychiatrist " Date: 1 November 2024