Comprehensive Geriatric Note

Nota preenchida

TIME: Not recorded

IDENTIFICATION: An older adult with mild mobility concerns was seen for a comprehensive geriatric assessment. Clinical frailty score: 4/9.

COLLATERAL CONTACTS:
Consent for collateral information was obtained. Family contact available; details omitted.

PAST MEDICAL HISTORY:
1. Hypertension
2. Osteoarthritis

MEDICATIONS:
Prescriptions are filled at the patient's usual pharmacy. Current medications include:
1. Antihypertensive medication; name and dose not confirmed

Allergies:
No known drug allergies reported.

HABITS:
Smoking: No current use reported.
Alcohol: Occasional.
Cannabis and other: None reported.

HISTORY OF PRESENT ILLNESS:
The patient describes gradual slowing while walking and one near-fall without injury. Uses a cane outdoors and remains interested in staying independent. No acute confusion or recent illness reported.

GERIATRIC REVIEW OF SYSTEMS:
1. Cognition: No new concern reported.
2. Mood: Mood is stable.
3. Falls: One near-fall; no injury.
4. Vision: Uses corrective lenses.
5. Hearing: No major concern reported.
6. Sleep: Generally adequate.
7. Nutrition: Appetite stable.
8. Pain: Intermittent joint discomfort.
9. Continence: No new concern reported.
10. Exercise tolerance: Walks short distances.
11. Abuse/neglect: No concern disclosed.

FUNCTIONAL HISTORY:
1. ADLs: Independent.
2. IADLs: Manages most tasks independently.
3. Adaptive equipment: Cane outdoors.
4. Community services: None currently.

SOCIAL HISTORY:
Lives with supportive family; enjoys reading and short walks.

EXAMINATION:
Comfortable; gait cautious with cane. No focal weakness observed.

COGNITIVE TESTING:
Brief screening completed; detailed score not available.

INVESTIGATIONS:
Labs: Not available. PFTs: Not available. ECHO: Not available. ECG: Not available.

GERIATRIC ISSUES AND RECOMMENDATIONS:
In summary, mobility and fall prevention are priorities. Review medications, continue safe activity, and consider balance-focused therapy.

Caso ilustrativo com dados de paciente inventados. Não é um registo real de paciente nem orientação clínica. Reveja cada nota à luz da sua própria consulta.

Factos clínicos por trás da nota

Estrutura reutilizável do modelo

TIME:  [Insert date and time]

IDENTIFICATION:  [Insert name of patient] is a [insert age in years] [insert gender] with a clinical frailty score of [#/9]. [Insert pronoun] was seen for a comprehensive geriatric assessment with concerns for [insert presenting concerns].

COLLATERAL CONTACTS:  
Consent for collateral information was obtained.  
1. [Name, phone number]  
2. [Name, phone number]  
(numeric list)

PAST MEDICAL HISTORY:  
1. [Condition]  
2. [Condition]  
(numeric list)

MEDICATIONS:  
Prescriptions are filled at [insert name and phone number of pharmacy]  
Current medications include:  
1. [Drug name, dosage, frequency]  
2. [Drug name, dosage, frequency]  
(numeric list)

Allergies:  
[Insert allergies or NKDA]

HABITS:  
Smoking: [Insert details]  
Alcohol: [Insert details]  
Cannabis and other: [Insert details]

HISTORY OF PRESENT ILLNESS:  
[Insert detailed history of present illness in detailed paragraphs]

GERIATRIC REVIEW OF SYSTEMS:  
1. Cognition: [Insert findings]  
2. Mood: [Insert findings]  
3. Falls: [Insert findings]  
4. Vision: [Insert findings]  
5. Hearing: [Insert findings]  
6. Sleep: [Insert findings]  
7. Nutrition: [Insert findings]  
8. Pain: [Insert findings]  
9. Continence: [Insert findings]  
10. Exercise tolerance: [Insert findings]  
11. Abuse/neglect: [Insert findings]

FUNCTIONAL HISTORY:  
1. ADLs: [Insert details]  
2. IADLs: [Insert details]  
3. Adaptive equipment: [Insert details]  
4. Community services: [Insert details]

SOCIAL HISTORY:  
Birth place: [Insert details]  
Education level: [Insert details]  
Occupation: [Insert details]  
Housing arrangement: [Insert details]  
Family: [Insert details]  
Attorney for personal care: [Insert details]  
Hobbies and interests: [Insert details]

EXAMINATION:  
[Insert physical exam findings]

COGNITIVE TESTING:  
[Insert cognitive testing results]

INVESTIGATIONS:  
Labs: [Insert relevant lab results]  
PFTs: [Report only FVC, FEV/FVC, DLCO]  
ECHO: [Report only EF and any valvular abnormalities]  
ECG: [Report rhythm and QTc]

GERIATRIC ISSUES AND RECOMMENDATIONS:  
In summary, [Insert summary and recommendations]