Retirement Home Note

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.