[GP Address]
1 November 2024
Dr. Eleanor Vance,
Re: Mrs. Agnes Willow
DOB: 12/03/1938
Thank you for referring Mrs. Willow, who was reviewed at Willowbrook Aged Care Facility on 1 November 2024. A Comprehensive Geriatric Assessment was performed. The issues discussed were:
Issues:
1. Agitation and Wandering
1. Impression: Moderate to severe Alzheimer's disease with associated behavioural and psychological symptoms of dementia (BPSD), including agitation and wandering. Likely Alzheimer's subtype.
Brodaty Scale: 18
Behavioural profile: Agitation, restlessness, pacing, and attempts to leave the facility unsupervised. Verbal aggression towards staff and other residents.
Treatment planned: Discontinue donepezil due to lack of efficacy and side effects. Start risperidone 0.5mg at night. Review in 2 weeks.
Non-Pharmacological: Implement a structured daily routine, provide regular opportunities for exercise and social interaction, and ensure a safe and familiar environment. Consider music therapy and aromatherapy.
Relevant Referrals: Referral to a geriatric psychiatrist for further assessment and management of BPSD.
2. Urinary Incontinence
[Document impression or likely diagnosis for this issue] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.)
Urge incontinence secondary to detrusor overactivity.
[Document differential diagnosis for this issue] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.)
Rule out urinary tract infection, constipation, and other reversible causes.
[Document investigations planned for this issue] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.)
Urinalysis and urine culture.
[Document treatment planned for this issue] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.)
Bladder training, fluid management, and consider anticholinergic medication if appropriate.
[Document relevant referrals for this issue] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.)
Referral to a continence nurse.
3. Poor Oral Intake
[Document impression or likely diagnosis for this issue] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.)
Poor oral intake secondary to dysphagia and decreased appetite.
[Document differential diagnosis for this issue] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.)
Rule out dental problems, medication side effects, and depression.
[Document investigations planned for this issue] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.)
Swallowing assessment by a speech pathologist.
[Document treatment planned for this issue] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.)
Modify diet to include thickened fluids and soft foods. Consider nutritional supplements.
[Document relevant referrals for this issue] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.)
Referral to a speech pathologist and a dietician.
Past Medical History
* Alzheimer's disease (diagnosed 2018)
* Hypertension (diagnosed 2010)
* Osteoarthritis (diagnosed 2015)
* Urinary Incontinence (diagnosed 2023)
BACKGROUND AND HISTORY
Mrs. Willow is an 86-year-old female with a diagnosis of Alzheimer's disease. She was referred for assessment of increasing agitation, wandering, and behavioural disturbances. She has been a resident at Willowbrook Aged Care Facility for the past 6 months. Her daughter reports that her mother's memory has been progressively declining over the past five years. She has difficulty with short-term memory and often repeats questions. She is frequently disoriented to time and place. Mrs. Willow's daughter states, "Mum gets very agitated in the afternoons and tries to leave the facility. She doesn't understand where she is going." She also has a history of hypertension and osteoarthritis. Mrs. Willow's mobility is limited due to her osteoarthritis, and she uses a walker for ambulation. She has experienced several falls in the past year, but no injuries have been reported. She has recently been experiencing urinary incontinence and poor oral intake.
Memory Concerns
Onset of memory decline was approximately five years ago. The pattern of decline is progressive, with increasing difficulty with short-term memory, and frequent repetition of questions. Family observations include difficulty remembering recent events and appointments.
Functional Decline
Loss of independence in Activities of Daily Living (ADLs) is evident. Mrs. Willow requires assistance with dressing, bathing, and toileting. She is unable to manage her medications independently. She is also unable to prepare meals or manage finances.
Living Environment & Family Support
Mrs. Willow resides at Willowbrook Aged Care Facility. Her daughter visits regularly and is actively involved in her care. She has two grandchildren who also visit occasionally. The family is supportive and involved in her care.
Systems Review
Weight Change: Unintentional weight loss of 5kg in the last 6 months.
Falls: History of falls in the last 12 months, with no injuries reported.
Mood: Frequently agitated and restless.
Sleep: Sleeps poorly, with frequent nighttime awakenings.
Pain: Reports mild pain in her knees due to osteoarthritis.
Mobility/Aids Used: Uses a walker for ambulation.
Bowels: Constipation.
Bladder: Urinary incontinence.
Memory: Significant memory impairment.
Hearing: No reported hearing loss.
Vision: No reported visual disturbances.
Medications on Initial Review
* Donepezil 5mg daily
* Lisinopril 10mg daily
* Paracetamol as needed for pain
Allergies
No known allergies.
Suggested Medications Following Consultation
Discontinue: Donepezil
Adjust: Risperidone 0.5mg at night
Social History
Lives: Willowbrook Aged Care Facility.
Children: One daughter.
Grandchildren: Two.
Born in: United Kingdom.
Emigrated to Australia in: 1960.
ADLs (Personal): Requires assistance with dressing, bathing, and toileting.
ADLs (Domestic): Unable to perform domestic activities.
Community Engagement: Limited social activities.
Services in place: Respite care for the daughter.
Driving: No longer drives.
Falls (last 12 months): Multiple falls.
Mobility Aid: Walker.
Education: Completed secondary school.
Employment History: Worked as a secretary.
EPOA/Guardianship: Enduring Power of Attorney in place.
My Aged Care: Registered with My Aged Care.
Smoking/Alcohol: Non-smoker, occasional alcohol consumption in the past.
Vaccinations: Up to date with vaccinations.
Family History: Mother had Alzheimer's disease.
Exercise: Limited exercise due to mobility issues.
Physical Examination
Heart Rate: 80 bpm
Blood Pressure: 140/80 mmHg
Neuro: Mini-Mental State Examination (MMSE) score of 12/30.
Weight: 55 kg
Gait: Slow and unsteady gait.
Pathology
Urinalysis pending.
Cognitive Assessment
Tool: Mini-Mental State Examination (MMSE)
Score: 12/30
Interpretation: Severe cognitive impairment.
Comments: Significant impairment in memory, orientation, and executive function.
Summary
Mrs. Willow is an 86-year-old female with a diagnosis of Alzheimer's disease, presenting with increasing agitation, wandering, urinary incontinence, and poor oral intake. The focus of treatment is to manage her behavioural symptoms, improve her functional status, and address her medical issues.
Follow-up
* Review in 2 weeks to assess response to risperidone.
* Follow-up with geriatric psychiatrist.
* Review of urinalysis results and management of urinary incontinence.
* Review of swallowing assessment and dietary modifications.
Kind regards,
Dr. Emily Carter
Geriatrician
Willowbrook Aged Care Facility
[GP Address]
[Date]
Dr [Referrer Name],
Re: [Patient Full Name]
DOB: [DD/MM/YYYY]
Thank you for referring [Patient First Name], who was reviewed at [Facility] on [Date of Review]. A Comprehensive Geriatric Assessment was performed. The issues discussed were:
Issues:
1. [List the first issue related to Behavioural and Psychological Symptoms of Dementia (BPSD)] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a heading.)
Impression: [Document diagnosis of BPSD, severity of dementia, and likely dementia subtype] ( Write as a brief description.)
Brodaty Scale: [Document the Brodaty Scale score]
Behavioural profile: [Document specific behavioural symptoms observed such as agitation, aggression, disinhibition, intrusive behaviours, wandering] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a brief description.)
Treatment planned: [Document medications to discontinue, adjust or start, including dosages, frequency and timing] (Write in complete sentences.)
Non-Pharmacological: [Document non-pharmacological interventions recommended] ( Write as a brief description.)
Relevant Referrals: [Document any referrals made for this issue] ( Write as a brief description.)
2. [List the second issue, problem or request] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a heading.)
[Document impression or likely diagnosis for this issue] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.)
[Document differential diagnosis for this issue] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.)
[Document investigations planned for this issue] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.)
[Document treatment planned for this issue] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.)
[Document relevant referrals for this issue] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.)
3.[List additional issues, problems or requests as needed, following the same format as above] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Follow the same format as previous issues.)
Past Medical History
[List all relevant medical conditions chronologically with dates where known] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list with each condition on a new line.)
BACKGROUND AND HISTORY
[Provide detailed background summary including presenting complaint, relevant history, social context, cognitive/functional changes, patient concerns, goals, and recent health events] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences, including narrative sections with patient and family quotes where available. Aim for at least 300 words of comprehensive information.)
Memory Concerns
[Document onset, pattern of memory decline, and family observations regarding memory issues] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
Functional Decline
[Document loss of independence in Activities of Daily Living and changes in functional abilities] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
Living Environment & Family Support
[Document patient's living situation before admission, family structure, recent changes, and level of family involvement] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
Systems Review
Weight Change: [Document information about recent weight changes] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Falls: [Document information about falls, including frequency, circumstances and injuries] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Mood: [Document information about mood, emotional state and behavioral symptoms] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Sleep: [Document information about sleep patterns and issues] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Pain: [Document information about pain, including location, severity and management] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Mobility/Aids Used: [Document information about mobility status and assistive devices] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Bowels: [Document information about bowel function] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Bladder: [Document information about bladder function and continence] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Memory: [Document information about memory function and cognitive changes] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Hearing: [Document information about hearing function and aids] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Vision: [Document information about vision, visual aids and visual disturbances] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Medications on Initial Review
[List all current medications with dosages and indications, noting recent changes, compliance issues, and adverse reactions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list.)
Allergies
[Document allergies and specific reactions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Suggested Medications Following Consultation
[Document recommended medication changes and reasons] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Discontinue: [List medications to discontinue] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Adjust: [List medications to adjust with new dosing] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Commence: [List new medications to start with dosing] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Social History
Lives: [Document current living situation] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Children: [Document information about children] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Grandchildren: [Document information about grandchildren] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Born in: [Document place of birth] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Emigrated to Australia in: [Document year of emigration if applicable] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
ADLs (Personal): [Document level of independence with personal activities of daily living] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
ADLs (Domestic): [Document level of independence with domestic activities of daily living] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Community Engagement: [Document information about social activities and community involvement] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Services in place: [Document current support services] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Driving: [Document driving status] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Falls (last 12 months): [Document fall history] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Mobility Aid: [Document mobility aids used] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Education: [Document educational background] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Employment History: [Document occupational history] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
EPOA/Guardianship: [Document legal arrangements] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
My Aged Care: [Document aged care services status] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Smoking/Alcohol: [Document substance use history] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Vaccinations: [Document vaccination status] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Family History: [Document relevant family medical history] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Exercise: [Document exercise habits and limitations] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Physical Examination
Heart Rate: [Document heart rate] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Blood Pressure: [Document blood pressure measurements] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Neuro: [Document neurological examination findings] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Weight: [Document weight] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Gait: [Document gait assessment] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Pathology
[Document recent pathology results or investigations ordered] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.)
Cognitive Assessment
Tool: [Document cognitive assessment tool used] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Score: [Document cognitive assessment score] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Interpretation: [Document interpretation of cognitive assessment results] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Comments: [Document additional observations about cognitive function] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Summary
[Provide a concise summary of the patient's age, diagnosis, current presentation, and treatment focus] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a paragraph of full sentences.)
Follow-up
[Document planned follow-up arrangements including dates and focus of future reviews] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences with each follow-up item on a new line.)
Kind regards,
[Insert Practitioner name]
[Insert Practitioner credentials]
[Practice/Facility Name]
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included 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.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
