Comprehensive Geriatric Assessment

Date and Visit Details:
Date: 2025-05-23 | Visit Type: In Person Visit

Patient ID confirmed & verbal consent obtained via self.
Attendees: None.
Time: 15:50-16:50
Referral Source: Not mentioned
Previous MRP: Not mentioned
Current HCC Care Coordinator: Not mentioned
Admitting SHS MRP: Not mentioned

Subjective:
Chronic Conditions:
Dementia (F03), Hypertension (I95)

Problem List:
- Bladder control issues (R39.82): Patient reports inability to control urination timing, with episodes of leakage upon standing.
- Dizziness (R42): Patient describes episodes of dizziness, particularly when sitting or standing.
- Weight gain (R63.5): Patient notes weight gain attributed to reduced mobility and dietary changes.
- Dementia (F03): Ongoing cognitive impairment noted in the nursing care setting.

Surgical/Medical History:
- Dementia (F03): Diagnosed previously, ongoing management in nursing care.
- No other surgical or medical history explicitly mentioned.

Devices:
Walker, Glasses

Family History:
None Recorded

History of Present Illness:
Jane Doe is an 85-year-old female with a history of dementia presenting with bladder control issues and dizziness. The patient reports difficulty controlling urination, with episodes of leakage occurring upon standing. She denies constipation, current bowel issues, or excessive bowel movements. She can urinate but cannot control the timing. The patient also denies having pain currently. She reports reduced mobility and attributes recent weight gain to dietary changes and decreased physical activity. She denies needing to walk off the weight gain or requiring new clothes due to the weight change. The patient denies using a wheelchair independently. She also reports episodes of dizziness, particularly when sitting or standing, which she describes as a spinning sensation.

Medications:
Administered by: Caregiver
Understanding: Good
Adherence: Good
Storage: Dosette
Intake Form: Whole
Pharmacy: Not mentioned
Active Medications: Not mentioned
External Medications: Not mentioned
OTC/Supplements: Not mentioned

Allergies:
None Known

Review of Systems:
General: Reports weight gain and reduced mobility.
Pain: Denies current pain.
Cognition: Dementia noted, with ongoing cognitive impairment.
Sensory: No specific sensory complaints mentioned.
Mood: Reports mood fluctuations, feeling isolated due to limited visitors.
Sleep: Not explicitly mentioned.
Mobility: Reduced mobility noted, uses a walker.
Appetite and Weight: Reports weight gain attributed to dietary changes and reduced activity.
Voiding and Bowel: Reports bladder control issues with leakage upon standing. Denies constipation or excessive bowel movements.

Safety Concerns:
Falls: Reports dizziness, which may increase fall risk.
Driving: Not applicable.
Fire Risk: Not mentioned.
Aggression: Not mentioned.
Wandering: Not mentioned.
Elder Abuse: None reported.

Advance Care Planning:
- Illness Understanding: Not explicitly discussed.
- Wishes & Values: Not explicitly discussed.
- Goals of Care/Code Status: Not mentioned

Preventative Health:
- Immunizations: Not mentioned
- Cancer Screening: Not mentioned

Social History:
The patient denies remembering certain visitors initially and reports having visitors only from her two children. She denies participating in social activities currently. The patient resides in a nursing care facility and reports limited interaction with other residents. She enjoys sitting outside with family members when weather permits.

Objective:
Functional Status:
Activities of Daily Living (ADLs):
- Independent for: Not mentioned
- Dependent for: Not mentioned
Instrumental Activities of Daily Living (IADLs):
- Independent for: Not mentioned
- Dependent for: Not mentioned
- Driver's License: Not Active

Home Care Services:
- Nursing care provided in the facility.

Mobility Aids:
- Walker

Adaptive Equipment:
- Glasses

Private Care: None

LTC Planning: Resides in a long-term care facility.

Physical Exams:
Vitals: Blood pressure 143/69 mmHg.
Orthostatic BP/HR: Not assessed.
Head & Neck: Not assessed.
Respiratory: Not assessed.
Cardiovascular: Not assessed.
Breast Exam: Not assessed.
Abdominal Exam: Not assessed.
Musculoskeletal: Not assessed.
Skin: Not assessed.
Neurological: Not assessed.

Investigations:
Recent Labs:
- Hgb: Not mentioned
- WBC: Not mentioned
- Platelets: Not mentioned
- Creatinine: Not mentioned
- Sodium: Not mentioned
- Potassium: Not mentioned
- Calcium: Not mentioned
- HbA1c: Not mentioned
- TSH: Not mentioned
- B12: Not mentioned
- LDL: Not mentioned
- INR: Not mentioned

Recent Imaging:
- ECG: Not mentioned
- CT/MRI Head: Not mentioned
- CXR: Not mentioned

Assessment and Plan:
Summary:
Jane Doe is an 85-year-old female with a history of dementia, presenting with bladder control issues and dizziness. She reports difficulty controlling urination and episodes of dizziness, particularly when sitting or standing. She also notes weight gain attributed to reduced mobility and dietary changes. The patient resides in a nursing care facility and reports limited social interaction.

Plan:
The patient will continue current medications as prescribed. Ongoing monitoring of bladder control and dizziness will be conducted. 

Preventative health measures include ensuring all immunizations are up-to-date. No additional investigations were ordered during this visit. 

The patient will remain under the care of nursing staff at the current facility. No new referrals to specialized health services are required at this time. 

Advance care planning, including goals of care and code status, will be addressed during future visits. Long-term care planning remains unchanged, with the patient continuing to reside in the nursing care facility. 

Safety precautions will focus on fall risk monitoring due to dizziness. 

A follow-up visit will be scheduled to reassess bladder control and dizziness.