Download Initial Geriatric consultation

Name:
DOB:
Age:
M F
Date:
Page: 1
INITIAL GERIATRIC CONSULTATION
Source of History:
 Patient
 Caregiver
 Family
 Friend
 Medical Records
Chief Concern(s):
HPI:
PMH:
Medications (List name and dosage):
Supplements:
Allergies:
Social History:
 Living Arrangements
FH:
Care Resources:
Personal History: (Reverse developmental milestones)
Functional Level: (Basic ADL's, IADL's, Driving)
Telephone Usage
 Do not use at all
 Answer the phone but do not dial
 Dial a few well-known numbers
 Use telephone at own initiative
 No access to telephone
Housekeeping
 Unable to perform any housekeeping tasks
 Needs help with all home maintenance tasks
 Perform light tasks (dishwashing, bed
making)
 Maintain house alone or with occasional
assistance
Shopping
 Unable to shop
 Needs to be accompanied to shop
 Shops independently for small purchases
 Shops independently
Transportation
 No travel at all
 Travel on public transportation if
accompanied
 Travel alone on public transportation
 Drive self
 Driven by friends/relatives or taxi
Name:
DOB:
Age:
M F
Date:
Page: 2
Check Areas Reviewed
Review of Systems:
 General: fevers, chills, malaise, fatigability, night
sweats, weight changes
 Neurologic: syncope, seizures, weakness,
paralysis, abnormal sensation/coordination,
tremors, memory loss
 Psychiatric: depression, mood changes, difficulty
concentrating, nervousness, tension, suicidal
ideation, irritability, sleep disturbances
 Sensory Functions: visual changes, hearing
changes, neuropathy, balance/coordination
 Motor Functions: gait, falls, ataxia
 Diet: preferences, restrictions (religious, allergic,
disease), vitamins/supplements, caffeine,
food/liquid intake diary, "look in fridge test", who
prepares/obtains food
 Skin: rash/eruption, itching, pigmentation,
excessive sweating, nail/hair abnormalities
 Head: Headaches, dizziness, syncope, severe head
injuries, loss of consciousness
 Eye: visual changes, blurring, diplopia,
photophobia, pain, eye medication use, eye trauma,
FH of eye disease
 Ears: hearing loss, pain, discharge, tinnitus, vertigo
 Nose: sense of smell, obstruction, epistaxis,
postnasal drip, sinus pain, rhinorrhea
 Oral: hoarseness, sore throat, gum
bleeding/soreness, tooth abscess/extraction, ulcers,
taste changes
 heat/cold intolerance, unexplained weight change,
diabetes, polydipsia, polyuria, facial/body hair
changes, increased hat/glove size, striae
 Musculoskeletal: joint stiffness, pain, limited
ROM, swelling, redness, heat, bone deformity
 Sexual: libido, intercourse frequency, sexual
difficulties, impotence
Abnormal Findings
Name:
DOB:
M F
Age:
Date:
Page: 3
 Gynecologic: itching, last Pap smear, menopause
age
 Breasts: pain, tenderness, discharge, lumps,
mammograms, self-breast exams
 Cardiac/Peripheral Vascular: Chest pain,
palpitations, dyspnea, orthopnea, edema,
claudication, HTN, previous MI, exercise
tolerance, previous cardiac studies
 Pulmonary: pleuritic pain, dyspnea, cyanosis,
wheezing, cough/sputum, hemoptysis, TB
exposure, previous CXR's
 Gastrointestinal: appetite, digestion, dysphagia,
heartburn, nausea, vomiting, hematemesis,
diarrhea, constipation, stool changes, flatulence,
hemorrhoids, hepatitis, jaundice, dark urine, history
of ulcers/gallstones/polyps/tumors, previous X-rays
 Renal/Urinary: dysuria, flank/suprapubic pain,
urgency, frequency, nocturia, hematuria, polyuria,
hesitancy, dribbling, force of stream changes,
STD's
 Hematologic: anemia (dizziness/fatigue/dyspnea),
easy bruising/bleeding, blood cell abnormalities,
transfusions
 Lymphatic: lymph node enlargement/tenderness
 Endocrine/Metabolic: thyroid enlargement/pain
Scale (0-10)
General Energy:
0
1
2
3
4
5
6
7
8
9
10
Malnutrition Indicator Score
A. Has food intake declined over the past 3 months due to loss of appetite, digestive
problems, chewing or swallowing difficulties?
0 = severe loss of appetite
1 = moderate loss of appetite
2 = no loss of appetite
B. Weight loss during the last 3 months
0 = weight loss greater than 3 kg (6.6 lbs)
1 = does not know
2 = weight loss between 1 and 3 kg (2.2 and 6.6 lbs)
3 = no weight loss
C. Mobility
0 = bed or chair bound
1 = able to get out of bed/chair but does not go out
2 = goes out
Name:
DOB:
Age:
M F
Date:
Page: 4
D. Has suffered psychological stress or acute disease in the past 3 months
0 = yes 2 = no
E. Neuropsychological problems
0 = severe dementia or depression
1 = mild dementia
2 = no psychological problems
F. Body Mass Index (BMI) (weight in kg) / (height in m)2
0 = BMI less than 19
1 = BMI 19 to less than 21
2 = BMI 21 to less than 23
3 = BMI 23 or greater
Screening score (subtotal max. 14 points)
12 points or greater Normal – not at risk – no need to complete assessment
11 points or below Possible malnutrition – continue assessment
G. Lives independently (not in a nursing home or hospital)
0 = no 1 = yes
H. Takes more than 3 prescription drugs per day
0 = yes 1 =no
I. Pressure sores or skin ulcers
0 = yes 1 =no
J. How many full meals does the patient eat daily?
0 = 1 meal
1 = 2 meals
2 = 3 meals
K. Selected consumption markers for protein intake
• At least one serving of dairy products (milk, cheese, yogurt) per day? yes no
• Two or more servings of legumes or eggs per week? yes no
• Meat, fish or poultry every day yes no
0.0 = if 0 or 1 yes
0.5 = if 2 yes
1.0 = if 3 yes
L. Consumes two or more servings of fruits or vegetables per day?
0 = no 1 = yes
M. How much fluid (water, juice, coffee, tea, milk…) is consumed per day?
0.0 = less than 3 cups
0.5 = 3 to 5 cups
1.0 = more than 5 cups
N. Mode of feeding
0 = unable to eat without assistance
1 = self-fed with some difficulty
2 = self-fed without any problem
Name:
DOB:
Age:
M F
Date:
Page: 5
O. Self view of nutritional status
0 = views self as being malnourished
1 = is uncertain of nutritional state
2 = views self as having no nutritional problem
P. In comparison with other people of the same age, how does the patient consider his/her
health status?
0.0 = not as good
0.5 = does not know
1.0 = as good
2.0 = better
Q. Mid-arm circumference (MAC) in cm
0.0 = MAC less than 21
0.5 = MAC 21 to 22
1.0 = MAC 22 or greater
R. Calf circumference (CC) in cm
0 = CC less than 31 1 = CC 31 or greater
Assessment (max. 16 points)
Screening score (subtotal max. 14 points)
Total Assessment (max. 30 points)
Malnutrition Indicator Score
17 to 23.5 points at risk of malnutrition
Less than 17 points malnourished
24-HOUR DIET REVIEW
Breakfast
Snack
Lunch
Snack
Dinner
Snack
Bowel Movements
Water Intake
Name:
DOB:
M F
Age:
Date:
Page: 6
Mini Mental Status Examination
The "Mini" Mental Status Exam is a quick way to evaluate cognitive function. It is often used to screen for dementia or
monitor its progression. [See Page 108 in Bates “A Guide to Physical Examination”, 6th Ed]
Date
Orientation
"Tell me the date?" Ask for omitted items.
One point each for year,
season, date, day of week,
and month
5
Place
Orientation
"Where are you?" Ask for omitted items.
One point each for state,
county, town, building,
and floor or room
5
Register 3
Objects
Name three objects slowly and clearly. [Ball – Flag – One point for each item
Tree] Ask the patient to repeat them.
correctly repeated
3
Serial Sevens
Ask the patient to count backwards from 100 by 7.
One point for each correct
Stop after five answers. (Or ask them to spell "world"
answer (or letter)
backwards.)
5
Recall 3
Objects
Ask the patient to recall the objects mentioned above.
Naming
Point to your watch and ask the patient "what is this?" One point for each correct
Repeat with a pencil.
answer
2
Repeating a
Phrase
Ask the patient to say "no ifs, ands, or buts."
One point if successful on
first try
1
Verbal
Commands
Give the patient a plain piece of paper and say "Take
One point for each correct
this paper in your right hand, fold it in half, and put it
action
on the floor."
3
Written
Commands
Show the patient a piece of paper with "CLOSE One point if the patient's
YOUR EYES" printed on it.
eyes close
1
Writing
Ask the patient to write a sentence.
One point for each item
correctly remembered
3
One point if sentence has a
subject, a verb, and makes
sense
1
One point if the figure has
ten corners and two
intersecting lines
1
Ask the patient to copy a pair of intersecting
pentagons onto a piece of paper.
Drawing
Scoring
A score of 24 or above is considered normal.
30
Name:
DOB:
Age:
M F
Date:
Page: 7
Geriatric Depression Scale
One point for each answer that is in parentheses
1.
Are you basically satisfied with your life? (no)
2.
Do you often get bored? (yes)
3.
Are you in good spirits most of the time? (no)
4.
Do you often feel helpless? (yes)
5.
Do you frequently worry about the future? (yes)
6.
Do you often feel downhearted and blue? (yes)
7.
Do you find life very exciting? (no)
8.
Do you feel that your situation is hopeless? (yes)
9.
Do you frequently feel like crying? (yes)
10. Do you prefer to avoid social gatherings? (yes)
11. Have you dropped many of your activities/interests? (yes)
12. Are you hopeful about the future? (no)
13. Are you afraid something bad is going to happen to you? (yes)
14. Do you often get restless and fidgety? (yes)
15. Do you feel that you have more problems with memory than most? (yes)
16. Do you feel pretty worthless the way you are now? (yes)
17. Is it hard for you to get started on new projects? (yes)
18. Do you think that most persons are better off than you are? (yes)
19. Do you have trouble concentrating? (yes)
20. Is it easy for you to make decisions? (no)
21. Do you feel that your life is empty? (yes)
22. Are you bothered by thoughts that you just cannot get out of your head? (yes)
23. Do you feel happy most of the time? (no)
24. Do you prefer to stay home at night, rather than go out and do new things? (yes)
25. Do you think it is wonderful to be alive now? (no)
26. Do you worry a lot about the past? (yes)
27. Do you feel full of energy? (no)
28. Do you frequently get upset over little things? (yes)
29. Do you enjoy getting up in the morning? (no)
30. Is your mind as clear as it used to be? (no)
Total Score
Cutoff score of 11 indicating depression (84% sensitive, 95% specific)
Name:
DOB:
Age:
M F
Date:
Page: 8
OBJECTIVE:
VITALS:
BP (Lying)
BP (Sit)
P:
P:
T:
RR:
SaO2:
Height(in):
Weight(lbs):
BMI:
ASSESSMENT:
PLAN:
Follow-Up:
BP (Stand)