Comprehensive Geriatric Assessment

Date and Visit Details:
Date: 2026-02-07 | Visit Type: In Person

Patient ID confirmed & verbal consent obtained via .
Attendees: Mr. Thompson, .
Time: 
Referral Source: 
Previous MRP: 
Current HCC Care Coordinator: 
Admitting SHS MRP: 

Subjective:
Chronic Conditions:
Hypertension, Diabetes Mellitus.

Problem List:
- Shortness of breath, worsening over the past two weeks, especially on exertion and when lying down.
- Bilateral lower extremity edema, progressive over the past two weeks.
- Recent weight gain of approximately 6 pounds in 10 days.
- History of hypertension and diabetes mellitus.

Surgical/Medical History:
Hypertension, Diabetes Mellitus. No history of heart attacks. No history of heart surgeries.

Family History:
Father had a myocardial infarction in his 60s.

History of Present Illness:
Mr. Thompson presents with a two-week history of worsening exertional dyspnea and orthopnea, requiring three pillows to sleep. He reports bilateral lower extremity swelling that worsens by the end of the day and a recent unintentional weight gain of approximately 6 pounds over 10 days. He denies chest pain but notes intermittent palpitations. He continues to take his antihypertensive and antidiabetic medications as prescribed.

Medications:
Administered by: Self
Understanding: Good
Adherence: Good
Storage: 
Intake Form: 
Pharmacy: 
Active Medications: Antihypertensive agent(s), Antidiabetic agent(s)
External Medications:
OTC/Supplements:

Allergies:
None Known.

Review of Systems:
General: Reports increased shortness of breath on exertion and at night. No chest pain. Reports recent weight gain. Pain: Denies pain. Cognition: No concerns reported. Sensory: No concerns reported. Mood: No concerns reported. Sleep: Reports orthopnea, requiring three pillows to sleep. Mobility: Reports dyspnea with minimal exertion. Appetite and Weight: Reports recent weight gain of 6 pounds in 10 days. Voiding and Bowel: No concerns reported.

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

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

Social History:
No social history provided.

Objective:
Functional Status:
Activities of Daily Living (ADLs):
    - Independent for: 
    - Dependent for: 
Instrumental Activities of Daily Living (IADLs):
    - Independent for: 
    - Dependent for: 
- Driver's License: 

Home Care Services:
- 

Mobility Aids:
- 

Adaptive Equipment:
- 

Private Care: 

LTC Planning: 

Investigations:
Recent Labs:
- Hgb: 
- WBC: 
- Platelets: 
- Creatinine: 
- Sodium: 
- Potassium: 
- Calcium: 
- HbA1c: 
- TSH: 
- B12: 
- LDL: 
- INR: 

Recent Imaging:
- ECG: 
- CT/MRI Head: 
- CXR: 

Assessment and Plan:
Summary:
Mr. Thompson is a male with a history of hypertension and diabetes mellitus who presents with progressive exertional dyspnea, orthopnea, bilateral lower extremity edema, and recent weight gain. Family history is notable for paternal myocardial infarction.

Plan:
Medical Management: Initiate low-dose furosemide. Advise on a low-sodium diet and daily weight monitoring. Educate on tracking fluid intake and output. Investigations: Order chest radiograph, electrocardiogram, echocardiogram, B-type natriuretic peptide, complete blood count, electrolytes, and renal function tests. Referrals: Refer to heart failure clinic for close follow-up.

Clinic Name: [Clinic Name]