Past Medical History:
- Hypertension
- Type 2 Diabetes
- Osteoarthritis
Past Surgical History:
- Right hip replacement (2018)
- Cataract surgery (2020)
Social History:
- ADLs: Independent with bathing, dressing, and toileting.
- IADLs: Manages finances with assistance, prepares simple meals.
Family History:
- Father: History of heart disease.
- Mother: History of Alzheimer's disease.
DNR Status:
- Full code.
MOCA Score:
- 24/30
Family/Ongoing Concerns:
- Daughter concerned about increasing forgetfulness.
Allergies:
- Penicillin
Medications:
- Lisinopril 20mg daily
- Metformin 500mg twice daily
- Ibuprofen 200mg as needed for pain
Subjective:
- Patient presents with a chief complaint of increasing forgetfulness and difficulty with word finding.
- Duration/Timing/Location/Quality/Severity/Context of complaint: Symptoms have been gradually worsening over the past 6 months. Patient reports difficulty remembering recent events and misplacing items. The quality of the forgetfulness is described as frustrating.
- Factors affecting symptoms: Stress appears to exacerbate symptoms.
- Progression of symptoms: Gradual worsening of memory and word-finding difficulties.
- Impact on daily activities: Difficulty with managing medications and finances.
- Associated symptoms: Occasional headaches.
Objective:
- Oriented to person, place, and time.
- Mildly impaired short-term memory.
- Normal gait and balance.
Assessment:
- Cognitive decline, likely early-stage dementia.
- Rule out other causes of cognitive impairment.
Plan:
- Order a complete blood count (CBC), comprehensive metabolic panel (CMP), and thyroid-stimulating hormone (TSH) to rule out other causes.
- Refer to a neurologist for further evaluation and management.
- Discuss medication options for cognitive support.
- Schedule a follow-up appointment in 4 weeks.
Past Medical History:
- [current diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Past Surgical History:
- [past surgeries] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Social History:
- [ADLs] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [IADLs] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Family History:
- [family history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
DNR Status:
- [DNR status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
MOCA Score:
- [MOCA score] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Family/Ongoing Concerns:
- [family/ongoing concerns] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Allergies:
- [allergies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Medications:
- [medications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Subjective:
- [describe presenting complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [duration/timing/location/quality/severity/context of complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [factors affecting symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [progression of symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [previous episodes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [impact on daily activities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [associated symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Objective:
- [objective findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Assessment:
- [assessment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Plan:
- [plan] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)