Scribe BC - Geriatric Consult

Introduction "Thank you for referring this patient to Geriatric Medicine for comprehensive geriatric assessment" Identification: 82-year-old female with a history of mild cognitive impairment, recent MMSE score of 24/30, living with her daughter, and has a standard power of attorney in place. She is not currently driving. Reason for consultation: Evaluation for progressive memory loss and functional decline. History of Present Illness: Cognition: - Short term memory problems including difficulty remembering recent conversations and appointments. - Speech and language difficulties including word finding problems. - Executive function problems including difficulty with planning and organizing daily tasks. - Current mood state including mild depression, with some irritability. - Depression and anxiety screening results: PHQ-9 score of 8. - Sleep concerns including difficulty falling asleep. Falls/mobility: - Falls history including one fall in the last 6 months, no injuries. - Changes in gait including shuffling. Advanced Care Planning: POA: Yes, her daughter is the designated person, with authority for both financial and healthcare decisions. Past Medical History: - Hypertension, osteoarthritis, and hypothyroidism. Family History: - Mother with Alzheimer's disease. Medication and Allergies: - Lisinopril 10mg daily, levothyroxine 50mcg daily, and acetaminophen as needed for pain. - No known drug allergies. Social History: - Living Situation: Lives with her daughter in a single-family home. - Marital status: Widowed. - Social support: Receives support from her daughter and a home health aide for assistance with bathing. - Educational status: Completed high school. - Occupation and retirement status: Retired teacher. Substance use: - Non-smoker. - Drinks alcohol occasionally, one glass of wine per week. Functional History: - Activities of daily living: Requires assistance with bathing. - Instrumental activities of daily living: Requires assistance with managing finances and medication management. - Mobility and gait assessment: Walks with a shuffling gait, uses a cane for stability. - Use of assistive devices: Uses a cane. - Driving status: Has stopped driving due to concerns about safety. Review of systems: - Weight: Stable. - Diet: Good appetite, eats three meals a day. - Pain: Mild osteoarthritis pain in her knees, managed with acetaminophen. - Sleep: Difficulty falling asleep, takes 1mg melatonin. - Urinary symptoms: No urinary symptoms. - Constipation: Occasional constipation, managed with dietary fiber. - Hearing Impairment: Mild hearing loss, uses hearing aids. Exam: Vitals: - Blood pressure: 130/80 mmHg, sitting. - O2 Saturation: 98% on room air. - Pulse: 72 bpm, regular. - General appearance: Alert and oriented, appears her stated age. - Cardiovascular examination: Regular heart rate, no murmurs. - Respiratory examination: Clear to auscultation bilaterally. - Abdominal examination: Soft, non-tender. - Neurological examination: Mild cognitive impairment noted on mental status exam. - Mental status examination: Oriented to person and place, but not time. Short-term memory impaired. Investigations: - Vitamin B12 and TSH levels are within normal limits. Impression: - Mild cognitive impairment with functional decline, likely related to early-stage dementia. Plan and Action: - Discussed the diagnosis of mild cognitive impairment and the potential for progression to dementia with the patient and her daughter. - Recommended a referral to an occupational therapist for home safety assessment and strategies to improve functional independence. - Recommended a referral to a social worker for support and resources. - We have decided to start Donepezil. I have applied for special authority. 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 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. - Work up ordered today include CBC, renal function, electrolytes, Ca, Mg, P, transaminases, 25-hydroxyvitamin D, TSH, and bone mineral densiometry. Treatment initiated today: Vitamin D 1000 IU po daily Follow-up: - Follow-up with Geriatric Medicine in three months to assess medication efficacy and monitor for any changes in cognitive or functional status. "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."