Identification:
Mrs. Eleanor Vance, [age 82], presents today for a comprehensive geriatric assessment with a focus on falls prevention. She reports a history of falls, including two falls in the past six months, both occurring at home. She is accompanied by her daughter, Sarah.
History of Presenting Illness:
Mrs. Vance reports experiencing dizziness and unsteadiness, particularly when standing up from a seated position. She describes this as orthostatic hypotension. She also notes a recent increase in muscle weakness in her legs, making it difficult to navigate stairs. She denies any loss of consciousness or head trauma associated with her falls. She also reports some mild neuropathy in her feet, which she believes contributes to her balance issues.
Past Medical History:
* Hypertension
* Osteoarthritis
* Type 2 Diabetes
* Previous myocardial infarction
Allergy:
Mrs. Vance has no known allergies.
Medication:
* Lisinopril 10mg daily
* Metformin 500mg twice daily
* Aspirin 81mg daily
* Bisoprolol 2.5mg daily
Social History:
Mrs. Vance is a retired teacher. She lives independently in her own home. She does not smoke and drinks alcohol occasionally. She denies any history of drug use.
Functional Review:
Mrs. Vance reports some difficulty with instrumental activities of daily living (IADLs), such as managing finances and preparing meals. She is independent with activities of daily living (ADLs), including bathing, dressing, and toileting.
Physical Examination:
General Exam: Blood pressure seated 130/80 mmHg, standing 110/70 mmHg, heart rate seated 72 bpm, standing 78 bpm, height 5'4", weight 145 lbs.
Falls Specific Assessment: Calculated falls risk score is high. Contributing deficits include core and hip strength weakness, impaired proprioception. Timed Up and Go score is 18 seconds. Gait speed is reduced. She is unable to hold tandem stance for more than 3 seconds.
Cognitive Screen: MMSE score 28/30, MoCA score 24/30.
Mood screening questionnaire: Geriatric Depression Scale score 3/15.
Investigations:
Vitamin D level pending.
Assessment and Plan:
1. Falls Risk: Mrs. Vance is at high risk for falls due to orthostatic hypotension, muscle weakness, impaired balance, and a history of falls. Contributing factors include sarcopenia and polypharmacy. Recommended baseline blood work includes a Vitamin D level. Suggested targeted exercises include balance training and lower extremity strengthening exercises. Patient will be provided with handouts on fall prevention and information for Physio for Seniors. Patient plans to start physiotherapy next week. Discussed low blood pressure/heart rate, orthostasis, and medication adjustments. Bisoprolol will be reviewed and potentially adjusted. Rationale for medication review is to address potential contributors to orthostatic hypotension.
2. Follow up: Follow-up appointment scheduled in 3 months to reassess falls risk and review progress.
"This document was created using AI Ambient Scribe and Front-End Speech Recognition software and may include incorrect spelling/words. Consent for usage of AI was obtained by patient/guardian."
Identification:
[patient identification details including age, gender, and reason for initial consultation, and any noted history of falls] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
History of Presenting Illness:
[details of the patient's presenting illness, including symptoms related to balance, daily task navigation, muscle weakness, use of mobility aids, challenges with stairs/handrails, history and progression of neuropathy, symptoms in hands, orthostatic symptoms and blood pressure changes, and presence/absence of syncope signs/symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
Past Medical History:
[patient's past medical history, including specific diagnoses, surgical procedures, and relevant medical events, formatted as a list with each item on a new line] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as a list.)
Allergy:
[patient's known allergies, or confirmation of no known allergies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
Medication:
[patient's current medications, including drug name, dosage, frequency, and any specific indications, formatted as a list with each item on a new line] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as a list.)
Social History:
[patient's social history, including retired profession, professional activities, smoking status, alcohol intake, and history of drug or substance use] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
Functional Review:
[patient's independence with Instrumental Activities of Daily Living (IADLs) and Activities of Daily Living (ADLs)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
Physical Examination:
General Exam: [patient's general physical examination findings, including blood pressure (seated and standing), heart rate (seated and standing), height, and weight] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
Falls Specific Assessment: [details of falls specific assessment, including calculated falls risk score, contributing deficits (e.g., core and hip strength), proprioception, Timed Up and Go score, gait speed, and ability to hold tandem or unipedal stance] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
Cognitive Screen: [results of cognitive screening tests, including MMSE score and MoCA score] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
Mood screening questionnaire: [results of mood screening questionnaire, including Geriatric Depression Scale score] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
Investigations: (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Assessment and Plan:
1. Falls Risk: [assessment of falls risk, including contributing factors (e.g., sarcopenia), recommended baseline blood work (e.g., Vitamin D level), suggested targeted exercises, specific exercise programs (e.g., Otago based program), provided handouts or contact information (e.g., Physio for Seniors), patient's plans regarding physiotherapy, and discussion of low blood pressure/heart rate, orthostasis, monitoring, and medication adjustments (e.g., bisoprolol), and rationale for medication review] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
(add in additional points if other issues are discussed)
2. Follow up: [plan for patient follow-up, including timeline] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences.) (always have follow up as the last point in the assessment and plan)
"This document was created using AI Ambient Scribe and Front-End Speech Recognition software and may include incorrect spelling/words. Consent for usage of AI was obtained by patient/guardian."
(Never come up with your own patient details, assessment, plan, interventions, evaluation, or 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.)
