admission-note-old

# 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