# MEDICAL REVIEW - Dr. Eleanor Vance
Patient: 82-year-old female
Admitting team: Geriatric Medicine
"Referred as:" Admitted from aged care facility with a 3-day history of confusion and decreased oral intake.
## BACKGROUND:
(bg::Hypertension) diagnosed in 2010, managed with medication.
(bg::Osteoarthritis) diagnosed in 2015, managed with analgesia.
(bg::Mild cognitive impairment) diagnosed in 2020, under review.
SUBSTANCES:
Smoking history – Non-smoker.
Other non-prescribed substances including last time used: Nil.
"CFS" 5
Social/Services:
Home situation and who patient lives with: Lives in a residential aged care facility.
Current and relevant previous employment: Retired.
Mobility status and whether they drive: Ambulates with a walker, does not drive.
Current level of in-home supports including paid and unpaid services: Receives assistance with all activities of daily living from aged care staff.
### MEDICATIONS:
Lisinopril 10mg daily,
Paracetamol 1g four times daily,
Donepezil 5mg daily,
How medications are taken (e.g. Webster, dosette, pill box): Webster pack.
Comment on adherence to medications: Adherent.
## HOPC:
History of presenting complaint, including quoted descriptions of symptoms such as pain, vertigo, hallucinations: The patient's daughter reports a 3-day history of increasing confusion, including episodes of disorientation and difficulty with short-term memory. The patient has also experienced a decreased appetite and reduced oral intake. No complaints of pain or other specific symptoms were elicited.
Symptoms elicited on systems review, including both positives and negatives: No fever, cough, or shortness of breath. No chest pain or palpitations. No abdominal pain, nausea, or vomiting. No urinary symptoms. No falls.
Collateral history: Daughter present and providing collateral history.
Statement of explanations given to patient: Explained the need for admission and investigations to the patient and her daughter.
Description of any advance care planning discussions including resuscitative plans: Patient has a current advanced care directive in place, which was reviewed with the daughter. The patient wishes to be treated with comfort measures only.
## EXAMINATION:
Observations at time of review, including values and trends: Temperature 37.2°C, heart rate 88 bpm, blood pressure 140/80 mmHg, SpO2 96% on room air. Alert but confused. Oriented to person but not place or time.
Clinical findings grouped by systems:
Neurological: Confused, disoriented. No focal neurological deficits.
Cardiovascular: Regular rhythm, no murmurs.
Respiratory: Clear to auscultation.
Abdomen: Soft, non-tender.
### INVESTIGATIONS:
Blood test results in the last 24 hours, each category on one line (e.g. electrolytes, renal function, liver function):
Electrolytes: Na+ 138 mmol/L, K+ 4.0 mmol/L, Cl- 102 mmol/L.
Renal function: Creatinine 80 umol/L, eGFR 65 mL/min/1.73m2.
Liver function: ALT 25 U/L, AST 28 U/L, ALP 80 U/L.
Results of orifice tests such as urine, sputum, etc. Include microbiology with resistances if applicable, one result per line: Urine dipstick negative for infection.
Imaging results: Chest X-ray clear.
ECG description: Sinus rhythm, no acute changes.
Special investigations relevant to presentation, e.g. stress test, lung function test: Nil.
## IMPRESSION:
(impression::82-year-old female with a history of hypertension, osteoarthritis, and mild cognitive impairment, presenting with acute confusion and decreased oral intake.)
(impression::Likely multifactorial cause for confusion, including possible urinary tract infection, dehydration, and medication side effects.)
(impression::Prognosis is guarded, depending on the underlying cause of the confusion and the patient's response to treatment.)
(impression::Differential diagnoses include urinary tract infection, pneumonia, dehydration, medication side effects, and delirium due to underlying medical conditions.)
(impression::Additional problems identified requiring management: Dehydration, risk of aspiration.)
### PLAN:
- Admission to a team or intention to discharge: Admission to Geriatric Medicine ward.
- Immediate management plan to stabilise patient: IV fluids, oxygen as required.
- Management items initiated for treatment of the primary diagnosis: IV fluids, review and adjustment of medications, urine culture and sensitivity.
- Statement on chemical/mechanical VTE prophylaxis, or note if contraindicated. If not mentioned, default to “VTE prophylaxis as charted”: VTE prophylaxis as charted.
- Management items related to additional issues: Monitor fluid balance, monitor for aspiration risk.
- Supportive management such as fluid restriction, BP targets, O2 saturation targets: Maintain BP <140/90 mmHg, maintain SpO2 >94%.
- Whether patient can eat and drink: Confirm whether patient can eat and drink.
- Further investigations arranged from this review: Repeat blood tests, urine culture, consider further imaging if clinically indicated.
- When next planned review will occur, and signs or symptoms to prompt urgent review: Review daily, or sooner if there is a change in clinical status.
- Advanced care planning follow-up, such as completing resuscitation plan: Continue to follow advanced care directive.
- Referrals to speciality teams: Geriatric Medicine team.
- Referrals to allied health teams: Nil.
Dr. Eleanor Vance, 1 November 2024, 14:30
# MEDICAL REVIEW - [Author name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[Patient age and sex] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[Admitting team] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
"Referred as:" [Summary of referral received] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
## BACKGROUND:
[Previous medical history with complications, previous treatment and year of diagnosis if available. Append "bg::" at the front of each diagnosis and enclose in parentheses, use + for dot points] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
SUBSTANCES:
[Smoking history – must be mentioned whether present or not] (Always include, even if stated as “Non-smoker”.)
[Other non-prescribed substances including last time used] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
"CFS" [Rockwood clinical frailty score based on functional status] (Only include if patient is over 65 years old and explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Social/Services:
[Home situation and who patient lives with] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[Current and relevant previous employment] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[Mobility status and whether they drive] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[Current level of in-home supports including paid and unpaid services] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
### MEDICATIONS:
[Medications patient currently takes with dose and timing, one per line, end each with a comma] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[How medications are taken (e.g. Webster, dosette, pill box)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[Comment on adherence to medications] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
## HOPC:
[History of presenting complaint, including quoted descriptions of symptoms such as pain, vertigo, hallucinations] (Use only transcript history. Do not use context unless there is contradictory history. Write in paragraph format.)
[Symptoms elicited on systems review, including both positives and negatives] (Use only transcript history. Do not use context unless there is contradictory history. Write in paragraph format.)
[Collateral history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[Statement of explanations given to patient] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[Description of any advance care planning discussions including resuscitative plans] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
## EXAMINATION:
[Observations at time of review, including values and trends] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[Clinical findings grouped by systems] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
### INVESTIGATIONS:
[Blood test results in the last 24 hours, each category on one line (e.g. electrolytes, renal function, liver function)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Present all symbols as HTML code.)
[Results of orifice tests such as urine, sputum, etc. Include microbiology with resistances if applicable, one result per line] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[Imaging results] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[ECG description] (Use only transcript description, not context. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[Special investigations relevant to presentation, e.g. stress test, lung function test] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
## IMPRESSION:
[(impression::Opening statement including age, sex, succinct description of functional status, and current primary diagnosis. Do not mention underlying conditions unless primary issue is an exacerbation of chronic condition.)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[(impression::Description of current clinical status relating to primary diagnosis)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[(impression::Statement on prognosis)] (Only include if prognosis is explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[(impression::Differential diagnoses particularly relating to proposed further investigations)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[(impression::Additional problems identified requiring management)] (Each additional problem should be given an individual line. Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
### PLAN:
- [Admission to a team or intention to discharge] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- [Immediate management plan to stabilise patient] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- [Management items initiated for treatment of the primary diagnosis] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- [Statement on chemical/mechanical VTE prophylaxis, or note if contraindicated. If not mentioned, default to “VTE prophylaxis as charted”.] (Always include.)
- [Management items related to additional issues] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else state “to be monitored.”)
- [Supportive management such as fluid restriction, BP targets, O2 saturation targets] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- [Whether patient can eat and drink] (If not mentioned in transcript, insert reminder: “Confirm whether patient can eat and drink.”)
- [Further investigations arranged from this review] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- [When next planned review will occur, and signs or symptoms to prompt urgent review] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- [Advanced care planning follow-up, such as completing resuscitation plan] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- [Referrals to speciality teams] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- [Referrals to allied health teams] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[Sign-off by author with time and date seen] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, or plan for continuing care – use only the transcript, contextual notes or clinical note as a reference for the information to include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.)
