"Thank you for referring this patient to Geriatric Medicine for comprehensive geriatric assessment"
Reason for Assessment:
- The patient was referred for assessment due to frequent falls and memory concerns.
- Collateral history was obtained from the patient's daughter.
History:
The patient, an 82-year-old female, has experienced increasing forgetfulness and has had three falls in the past six months.
Cognition:
- Cognitive domains affected include short term memory and executive function.
- Short term Memory issues: The patient struggles to recall recent events and often misplaces items.
- Executive function: Difficulty in planning and organizing daily activities.
- Mood: The patient appears mildly anxious but denies feeling depressed.
- Hallucinations: No hallucinations reported.
- Sleep concerns: Yes, the patient reports difficulty falling asleep and frequent awakenings.
Falls/mobility:
- Dizziness with postural change: Yes, the patient experiences dizziness when standing up quickly.
- Tremor: No.
- Falls: Yes, the patient has had three falls recently, one resulting in a minor wrist injury.
- Change in gait: Yes, the patient has a shuffling gait.
Medical History:
- Past medical history includes hypertension and osteoarthritis.
- Previous surgeries: Hip replacement in 2018.
Functional Assessment:
- Activities of daily living (ADLs): The patient requires assistance with bathing and dressing.
- Instrumental activities of daily living (IADLs): The patient struggles with managing finances and medication.
- Mobility and gait: The patient uses a walker for stability.
Social History:
- Living situation: Lives alone in a single-story home.
- Support system: Regular visits from her daughter and a home care nurse.
- Occupation and retirement status: Retired school teacher.
- Alcohol, tobacco, and substance use: Occasional glass of wine, non-smoker.
Other Geriatric Syndromes:
- Falls: Yes, as noted above.
- Weight changes: No significant changes.
- Dietary intake: Balanced diet with adequate nutrition.
- Chronic pain issues: Mild joint pain due to osteoarthritis.
- Sleep issues: Yes, as noted above.
Physical Examination:
- Vital signs: Blood pressure 140/85 mmHg, heart rate 72 bpm.
- General appearance: Alert and oriented, but appears frail.
- Cardiovascular system: Regular heart sounds, no murmurs.
- Respiratory system: Clear breath sounds bilaterally.
- Abdominal examination: Soft, non-tender.
- Musculoskeletal system: Decreased range of motion in hips.
- Neurological examination: Mild weakness in lower limbs.
Investigations:
- Neuroimaging: CT scan shows mild cerebral atrophy.
- Pertinent lab work: B12, TSH, and calcium levels are within normal limits.
Impression:
The patient presents with cognitive decline, likely due to early Alzheimer's disease, and recurrent falls possibly related to postural hypotension.
Plan and Recommendations:
- Management plan: Initiate fall prevention strategies and cognitive support.
- Referrals to specialists or services: Referral to physiotherapy for balance training.
- Donepezil: We have decided to start Donepezil. I have applied for Blue Cross special authorization. I have prescribed 5mg p.o. daily with a goal to increase to 10mg p.o. daily in 4 weeks if tolerated. We discussed the risks/benefits of Cholinesterase inhibitors. I advised that they are considered cognitive enhancers and indicated for mild/early Alzheimerβs disease or Lewy Body Dementia. They are not a cure nor do they stop the progression. Approximately one third of patients see some cognitive and functional benefit, one third maintain at their current state longer and one third continue to decline at the same rate. These medications have several side effects including GI upset, diarrhea, anorexia, sleep disturbances, bradycardia, falls, dizziness. They are contraindicated in patients with bradycardia or conduction abnormalities.
Follow-up: Schedule a follow-up appointment in 6 weeks to assess medication tolerance and effectiveness.
"Thank you for referring this patient to Geriatric Medicine for comprehensive geriatric assessment"
Reason for Assessment:
- [Reason for referral or assessment] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [collateral history was obtained from] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
History:
summarize the history
Cognition:
- "Cognitive domains affected include" (summarize if the following domains are affected: short term memory, speech and language, visual perceptual, praxis, divided attention, executive function)
- [Short term Memory issues] (include details only if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [speech and language issues] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [word finding issues] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [visual or perceptual disturbances] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [executive function] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [social skills] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [attention issues] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Mood] (Describe in detail)
- [Depression and anxiety screening results] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [hallucinations] (answer yes or no. include details only if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [sleep concerns] (answer yes or no and describe in detail)
Falls/mobility:
- [dizziness with postural change] (yes or no. If yes describe in detail)
- [tremor] (answer yes or no. If yes describe in detail)
- [falls] (answer yes or no. if yes describe in detail)
- [change in handwriting] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [change in gait] (yes or no. If yes describe in detail)
- [injury] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Medical History:
- [Past medical history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Previous surgeries] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Functional Assessment:
- [Activities of daily living (ADLs)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Instrumental activities of daily living (IADLs)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Mobility and gait] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Use of assistive devices] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Screening test results (e.g., MMSE, MoCA)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Social History:
- [Living situation] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Support system] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Occupation and retirement status] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Alcohol, tobacco, and substance use] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Other Geriatric Syndromes:
- [falls]
- [Weight changes]
- [Dietary intake]
- [chronic pain issues]
- [sleep issues]
Physical Examination:
- [Vital signs] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [General appearance] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Cardiovascular system] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Respiratory system] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Abdominal examination] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Musculoskeletal system] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Neurological examination] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Investigations:
- [Neuroimaging] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Pertinent lab work] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank. If discussed include B12, TSH, calcium even if normal) (include when I saw that results were normal)
Impression:
write an impression
Plan and Recommendations:
- [Management plan] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Referrals to specialists or services] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Donepezil]: (only include if explicitly mentioned in the transcript, otherwise leave blank. If decision made to start this medication add the following phrases
- We have decided to start Donepezil. I have applied for Blue Cross special authorization.
- I have prescribed 5mg p.o. daily with a goal to increase to 10mg p.o. daily in 4 weeks if tolerated.
We discussed the risks/benefits of Cholinesterase inhibitors. I advised that they are considered cognitive enhancers and indicated for mild/early Alzheimerβs disease or Lewy Body Dementia. They are not a cure nor do they stop the progression. Approximately one third of patients see some cognitive and functional benefit, one third maintain at their current state longer and one third continue to decline at the same rate. These medications have several side effects including GI upset, diarrhea, anorexia, sleep disturbances, bradycardia, falls, dizziness. They are contraindicated in patients with bradycardia or conduction abnormalities.) (If we decide not to start donepezil describe the details around this decision.)
Follow-up: (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
