UBC Comprehensive Geriatric Assessment

Today I saw Mrs. Evelyn Reed in person at the Geriatric Clinic on 1 November 2024. Mrs. Reed is a 82 years-old female seen for a comprehensive geriatric assessment. PAST MEDICAL HISTORY: * Hypertension, Dr. Smith * Osteoarthritis, Dr. Jones * Osteoporosis, Dr. Jones * Depression, Dr. Brown MEDICATIONS: * Lisinopril 10mg daily * Acetaminophen 500mg PRN * Calcium/Vitamin D supplement * Sertraline 50mg daily ALLERGIES: * NKDA HISTORY OF PRESENT ILLNESS: Mrs. Reed presents for a comprehensive geriatric assessment. She reports increasing difficulty with mobility and some memory concerns. She denies chest pain, shortness of breath, or falls. She is independent with all ADLs but has some difficulty with iADLs such as managing finances. REVIEW OF SYSTEMS: * CNS events: No recent falls or syncope. * Cognition: Reports some memory difficulties, especially with recent events. * Mood: Reports feeling down at times but denies significant depressive symptoms. * Falls/Mobility: Reports some unsteadiness when walking, especially on uneven surfaces. * Bone health: Reports history of osteoporosis. * Hearing/Vision: Wears glasses for distance vision and uses hearing aids. * Sleep: Reports difficulty falling asleep and staying asleep. * Nutrition: Eating well, no significant weight changes. * Continence: Continent of bowel and bladder. FUNCTIONAL HISTORY ADLs: Mrs. Reed is independent with bathing, dressing, toileting, and feeding. iADLs: Mrs. Reed has some difficulty with managing finances and medication management. Mrs. Reed uses a cane for ambulation. SOCIAL HISTORY: * Education: Completed high school. * Employment: Retired from a secretarial position 15 years ago. * Support/Living: Lives alone in her own home. Has a daughter who lives nearby and provides some support. * Hobbies: Enjoys reading and gardening. * Advanced care planning: Has a living will and a healthcare proxy. * Substance use: Non-smoker, drinks alcohol occasionally, denies recreational drug use. FAMILY HISTORY: * Siblings: Sister with a history of diabetes. * Maternal: Mother had Alzheimer's disease. * Paternal: Father had a history of heart disease. * Family history of dementia. EXAMINATION: Mrs. Reed is right-handed. Alert and oriented to person, place, and time. Affect is appropriate. Speech is clear. Vitals: BP 130/80, HR 72, RR 16, Temp 37.0C, sitting and standing. General: Well-appearing elderly female. HEENT: Pupils equal, round, and reactive to light. Hearing aids in place. Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops. Respiratory: Clear to auscultation bilaterally. Abdomen: Soft, non-tender, no masses. Neurological: Cranial nerves II-XII intact. Strength 5/5 in all extremities. Gait is slow and unsteady. Cognitive screening results (MoCA): 22/30 Prior cognitive testing: MMSE 24/30, 6 months ago. INVESTIGATIONS: * CBC: WNL * CMP: WNL * TSH: WNL * Vitamin D: 28 (L) PHARMACY: CVS Pharmacy ASSESSMENT & PLAN: 1. Cognitive Impairment: * Rationale: MoCA score of 22/30, history of memory complaints, and family history of dementia. * Plan: Schedule a follow-up cognitive assessment in 6 months. Discussed strategies for memory improvement. 2. Mobility Issues: * Rationale: Slow gait, reports unsteadiness. * Plan: Refer to physical therapy for gait and balance training. Recommend home safety assessment. 3. Vitamin D Deficiency: * Rationale: Vitamin D level of 28. * Plan: Prescribe Vitamin D supplementation. Plan for follow up: Follow up in 3 months. They were invited to contact the clinic if concerns arise sooner. Thank you for the opportunity to participate in the care of your patient. Dr. Thomas Kelly, MD, FRCPC Geriatric Medicine and Internal Medicine 99214, 30 minutes, 10 minutes I consent to the use of AI scribe technology to assist in the creation of my medical documentation.