Chronic Disease Follow-Up

VISIT INFORMATION:
Date: 2025-11-10
Visit Type: Home Visit
Patient ID Confirmed: Yes
Consent Obtained: Yes
Attendees: Patient

Subjective:
REASON FOR VISIT:
Routine chronic disease follow-up
Medication review

INTERIM HISTORY:
Interval Events:
None
Details: No hospitalizations, emergency department visits, or specialist visits reported since the last encounter. She denies past surgical history.

New Symptoms or Changes:
Fatigue, generalized weakness, mild confusion, memory loss. No new dyspnea, chest pain, edema, or weight change reported.
Details: She is mostly bed-bound by preference, with bilateral knee contractures and incontinence of bowel and bladder. No falls reported.

Disease-specific Status (for each major chronic condition):
Hypertension control (BP readings): Blood pressure is well controlled at 115/67 mmHg on no antihypertensive medications.
COPD symptoms (cough, SOB, sputum): Chronic obstructive pulmonary disease is stable on room air, with use of as needed albuterol and no maintenance medications. No acute respiratory symptoms reported.
Dementia symptoms (function, behavior changes): She is alert with intermittent mild confusion and memory loss.
Arthritis (pain, function): Severe osteoarthritis with non-ambulatory status, bilateral knee contractures, and chronic pain managed with as needed analgesics.
Osteoporosis (fracture risk, falls): No new fractures or falls reported.

MEDICATION REVIEW:
MINTOX REGUL SUS MINT Give 10 ml by mouth every 6 hours as needed for indigestion
Albuterol Sulfate HFA 108 (90 Base) MCG/ACT Aerosol, solution	
2 puff inhale orally every 8 hours as needed for SOB unsupervised self-administration Rinse mouth after use
oxyCODONE HCl Tablet 5 MG Give 0.5 tablet by mouth every 6 hours as needed for pain
Nasal Spray Nasal Solution (Oxymetazoline HCl)	
2 spray in both nostrils every 24 hours as needed for congestion unsupervised self-administration may keep at bedside
Milk of Magnesia Suspension 1200 MG/15ML (Magnesium Hydroxide)	
Give 30 ml by mouth every 24 hours as needed for Constipation IF NO BOWEL MOVEMENT IN 3 DAYS
Dulcolax Suppository 10 MG (Bisacodyl) Insert 1 suppository rectally every 24 hours as needed for Constipation IF NO RESULT FROM MILK OF MAGNESIA, ADMINISTER DULCOLAX SUPPOSITORY RECTALLY AT BEDTIME FOR CONSTIPATION
Fleet Oil Enema (Mineral Oil)	
Insert 1 dose rectally every 24 hours as needed for Constipation IF NO RESULTS FROM DULCOLAX, ADMINSITER FLEET ENEMA RECTALLY DAILY AS NEEDED FOR CONSTIPATION
Loperamide HCl Capsule 2 MG	
Give 1 capsule by mouth every 6 hours as needed for diarrhea after each loose stool
Advil Oral Tablet 200 MG (Ibuprofen) Give 2 tablet by mouth every 12 hours as needed for Pain May keep at bedside
Orajel 2X Toothache & Gum Mouth/Throat Gel 20-0.26 % (Benzocaine-Menthol (Mouth-Throat))	
1 application dental every 2 hours as needed for oral/teeth pain
Chlorhexidine Gluconate Solution 0.12 % Give 5 mg/ml by mouth every 12 hours as needed for gingivitis swish and spit
Tylenol Extra Strength Tablet 500 MG (Acetaminophen)	Give 2 tablet by mouth every 6 hours as needed for mild pain/fever Do not exceed 3000 mg of acetaminophen in 24 hours from all sources
Refresh Tears Ophthalmic Solution 0.5 % (Carboxymethylcellulose Sodium (Ophth)) Instill 1 drop in both eyes every 8 hours as needed for dry eye Instill 1 drop in both eyes every 8 hours as needed for dry eyes unsupervised self-administration may keep at bedside
Calmoseptine External Ointment 0.44-20.6 % (Menthol-Zinc Oxide)	
Apply to sacrum topically two times a day for MASD

REVIEW OF SYSTEMS:
General: Fatigue, generalized weakness, no fever, no chills, stable weight
Pain: Chronic pain
Cognition/Mood: Mild confusion, memory loss
Mobility/Falls: Bed-bound by preference, bilateral knee contractures, no falls
Voiding/Bowel: Incontinent of bowel and bladder, no constipation, no dysuria, no diarrhea
Other: Hard of hearing, fragile skin, decreased muscle tone, no nausea, no vomiting, no bilateral extremity edema

FUNCTIONAL STATUS:
ADLs: Dependent, mostly bed-bound by preference
IADLs: Dependent


Objective:
VITALS:
BP: 115/67 mmHg
Weight: 114 pounds


SAFETY SCREENING:
Home safety confirmed

PREVENTIVE HEALTH STATUS:
Vaccination Update: Not assessed
Bone Health: Not assessed
Cancer Screening: Not assessed

ADVANCE CARE PLANNING:
Goals of Care Discussed: Not assessed
Code Status Confirmed: DNR

Plan:
PLAN:
Medical Management Adjustments: No changes
Hypertension control (BP readings): Blood pressure is well controlled at 115/67 mmHg on no antihypertensive medications.
COPD symptoms (cough, SOB, sputum): Chronic obstructive pulmonary disease is stable on room air, with use of as needed albuterol and no maintenance medications. No acute respiratory symptoms reported.
Dementia symptoms (function, behavior changes): She is alert with intermittent mild confusion and memory loss.
Arthritis (pain, function): Severe osteoarthritis with non-ambulatory status, bilateral knee contractures, and chronic pain managed with as needed analgesics.
Osteoporosis (fracture risk, falls): No new fractures or falls reported.