Geriatrics Acute/Symptom-Driven Intake

1. Chief Complaint (CC):

Caregiver reports that the patient experienced a fall at home about three weeks ago, preceded by sudden dizziness without tripping or slipping. Since then, the patient has been feeling weak and unsteady on his feet.

 

2. History of Present Illness (HPI):

Approximately three weeks ago, the patient fell at home after feeling dizzy suddenly; no clear trigger such as tripping or slipping was reported. The patient’s memory reliability is questionable due to early-stage Alzheimer's. Since the fall, the patient experiences weakness and unsteadiness, particularly when moving around the house. Symptoms tend to occur when standing up or turning quickly, followed by dizziness. No clear pattern regarding time of day or other triggers was identified. No mention of treatments tried or symptom relief. No reported nausea, vomiting, or tinnitus associated with dizziness.

 

3. Review of Systems (ROS – geriatric-focused):

- Neurologic: Dizziness and unsteadiness on feet; no new confusion or memory changes since the fall (baseline early-stage Alzheimer’s).

- Musculoskeletal: Weakness reported during movement.

- Cardiovascular/Respiratory: No chest pain, shortness of breath, or palpitations reported.

- Other: No nausea or vomiting, but some ear ringing reported. No reported changes in vision or hearing. No mention of incontinence or mood changes.

 

4. Current Medications:

- Metformin (dose not specified). No anticoagulants or sedatives reported that might contribute to fall risk.

 

5. Functional Status:

The patient has some difficulty with balance and weakness when moving around the house, particularly when standing up or turning quickly, leading to unsteadiness. No explicit mention of changes in ability to perform ADLs or IADLs, but the reported symptoms suggest increased fall risk and possible mobility limitations. Memory baseline is impaired due to early-stage Alzheimer’s but no recent decline noted post-fall.