Blank Geriatric Health Medical Report

Blank Geriatric Health Medical Report

Patient Information

Patient Name:

[Your Name]

Patient ID:

123456789

Date of Birth:

January 1, 2050

Gender:

Female

Contact Information:

123-456-7890

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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