Free Blank Geriatric Health Medical Report

Patient Information

Medical History

1. Past Medical History:

   • Hypertension: Diagnosed in 2010, well-controlled with medication.

   • Type 2 Diabetes Mellitus: Diagnosed in 2015, managed with Metformin and lifestyle modifications.

   • Osteoarthritis: Diagnosed in 2018; primarily affects knees and hands.

   • Hyperlipidemia: Diagnosed in 2019, treated with statins.

   • Depression: History of mild depression, treated with counseling and occasional use of sertraline.

2. Family Medical History:

   • Mother: Heart Disease (passed at age 82)

   • Father: Diabetes (passed at age 75)

   • Siblings: One sister with osteoporosis

3. Medication List:

   • Lisinopril: 10 mg once daily for hypertension

   • Metformin: 500 mg twice daily for diabetes

   • Ibuprofen: 400 mg as needed for pain

   • Atorvastatin: 20 mg once daily for hyperlipidemia

   • Sertraline: 50 mg once daily for depression

4. Allergies:

   • Penicillin: Rash and itching

   • Aspirin: Gastrointestinal upset

Assessment Information

1. Chief Complaint:

   • “I’ve been feeling more tired than usual and have some pain in my knees. I’ve also noticed some swelling.”

2. History of Present Illness:

   • Mr. Doe reports increased fatigue over the past two months, which he attributes to disrupted sleep patterns and pain in his knees. He describes the knee pain as a 6/10 in intensity, worsening with prolonged standing and improving with rest. Denies fever, chills, or recent weight loss, but notes increased thirst and urination.

3. Review of Systems:

   • General: Increased fatigue, no weight loss

   • Cardiovascular: Occasional palpitations, denies chest pain, shortness of breath on exertion

   • Respiratory: No cough or wheezing, occasional mild dyspnea with exertion

   • Gastrointestinal: Normal appetite, regular bowel movements, no nausea or vomiting

   • Genitourinary: Increased urination, nocturia twice a night

   • Musculoskeletal: Knee pain and swelling, no recent injuries, mild stiffness in the morning

   • Neurological: No dizziness, headaches, or visual disturbances

   • Psychiatric: Mild depressive symptoms, no suicidal ideation

Physical Examination

1. Vital Signs:

   • Blood Pressure: 130/85 mmHg (sitting)

   • Heart Rate: 72 bpm (regular rhythm)

   • Respiratory Rate: 18 breaths/min (unlabored)

   • Temperature: 98.6°F

2. General Appearance:

   • Alert, cooperative, overweight (BMI: 28), dressed appropriately, appears well-nourished.

3. Cardiovascular Examination:

   • Heart sounds: Regular rhythm, no murmurs, good peripheral perfusion.

4. Respiratory Examination:

   • Clear lung fields on auscultation, no wheezes or crackles.

5. Abdominal Examination:

   • Soft, non-tender, no organomegaly, bowel sounds present.

6. Neurological Examination:

   • Alert and oriented to person, place, and time. Cranial nerves II-XII intact. Reflexes: 2+ throughout.

7. Musculoskeletal Examination:

   • Knees: Bilateral mild swelling, tenderness on palpation, reduced range of motion (flexion limited to 90 degrees). Crepitus noted with movement.

   • Hands: Mild stiffness and swelling in the distal joints, no deformities.

   • Gait: Slightly antalgic with increased pain on weight-bearing.

Functional Assessment

1. Activities of Daily Living (ADLs):

   • Bathing: Independent, but reports difficulty bending to wash feet.

   • Dressing: Needs assistance with putting on socks and shoes due to knee pain.

   • Eating: Independent; enjoys cooking simple meals.

2. Instrumental Activities of Daily Living (IADLs):

   • Cooking: Independent; prefers easy recipes.

   • Cleaning: Needs assistance with vacuuming and heavy lifting.

   • Shopping: Independent; prefers online shopping to avoid physical stores.

3. Cognitive Function:

   • No apparent memory deficits. Able to recall recent and past events. Engages in puzzles and reading to stimulate cognitive function.

Diagnostic Tests

1. Laboratory Results:

   • HbA1c: 7.2% (target <7%)

   • Lipid Panel: Total cholesterol: 190 mg/dL, LDL: 110 mg/dL, HDL: 45 mg/dL, Triglycerides: 150 mg/dL.

   • Complete Blood Count (CBC): Within normal limits, no anemia.

2. Imaging Studies:

   • X-ray of knees: Mild osteoarthritis changes with joint space narrowing, no significant effusion.

3. Other Relevant Tests:

   • Electrocardiogram (EKG): Normal sinus rhythm, no ST changes.

Diagnosis

1. Fatigue likely secondary to chronic disease management and possible sleep disturbance.

2. Osteoarthritis of the knees, bilateral.

3. Type 2 Diabetes Mellitus, poorly controlled; consider adjustment of diabetes management.

4. Mild depressive symptoms requiring further evaluation.

Plan of Care

1. Treatment Recommendations:

   • Continue current medications; consider adjusting Metformin dosage for better glycemic control.

   • Initiate physical therapy focused on strengthening and range of motion exercises for the knees.

   • Schedule a sleep study to evaluate for possible sleep apnea due to increased daytime fatigue.

2. Referrals to Specialists:

   • Referral to a rheumatologist for osteoarthritis management.

   • Referral to a dietitian for personalized dietary guidance focused on diabetes management.

3. Follow-up Appointment Schedule:

   • Schedule follow-up in 3 months for reassessment of diabetes control and knee pain management.

4. Lifestyle Modifications:

   • Encourage regular low-impact exercise (e.g., walking, swimming) for joint health and blood sugar control.

   • Dietary modifications: increase fiber intake, reduce refined sugars, and monitor carbohydrate intake.

Notes and Observations

• Mr. Doe’s daughter expresses concern about his mobility and overall health; recommend considering home health services for support.

• Discussed importance of social engagement to help alleviate depressive symptoms; suggest joining a local senior activity group.

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