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Fourth Week in Geriatric Primary Care: Navigating Complexity and Celebrating Small Victories
My fourth week in clinical rotation at a bustling gerontology primary care office has been incredibly enriching and, at times, humbling. The pace is different from acute care settings; here, the focus is on longitudinal relationships, complex polypharmacy, and the subtle presentations of illness in our older adult population. This week, I’ve had more autonomy in conducting initial assessments and formulating differential diagnoses, which has been both challenging and incredibly rewarding.
Challenges and Successes
Challenges: One significant challenge this week was managing the sheer volume of information. Many older adults present with multiple comorbidities, a long list of medications, and often, vague or overlapping symptoms. For instance, differentiating between cognitive changes due to a urinary tract infection (UTI), a new medication side effect, or worsening dementia required meticulous attention to detail and careful questioning. I found myself frequently reviewing medication lists and cross-referencing past medical history, which can be time-consuming. Another challenge was sometimes overcoming patient and family hesitancy to discuss sensitive topics, like urinary incontinence or cognitive decline, due to embarrassment or fear.
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Successes: My biggest success this week was definitely improving my efficiency in history-taking while still gathering comprehensive data. I also felt much more confident in my physical assessment skills, particularly the neurological and gait assessments crucial in geriatrics. Perhaps my proudest moment was accurately identifying a subtle sign of dehydration in a patient whose family attributed her lethargy solely to “old age,” prompting early intervention. Additionally, establishing rapport with several patients and seeing them respond positively to my questions and education felt like a significant step forward in building therapeutic relationships.
Patient Assessment: Mrs. K.O.
Chief Complaint (CC): “My husband says I’m more forgetful lately, and I’ve been tripping a bit.”
History of Present Illness (HPI): Mrs. K.O. is an 82-year-old Caucasian female accompanied by her husband. Her husband reports a 3-week history of increased forgetfulness, particularly regarding recent events and appointments. He notes she has been misplacing items more frequently. He also reports two “near falls” in the past week, where she stumbled but caught herself, attributing it to “clumsiness.” Mrs. K.O. herself acknowledges feeling “a little foggy” but denies significant memory issues or gait problems. She denies fever, chills, dysuria, or pain. Bowel movements are regular. She states her appetite is good, but her husband notes she hasn’t been finishing her meals as usual.
Past Medical History (PMH): Hypertension, Type 2 Diabetes Mellitus (well-controlled on oral medications), Osteoarthritis, Hypothyroidism.Surgical History (PSH): Cholecystectomy (age 60), Left Hip Replacement (age 75).Medications: Lisinopril 10mg daily, Metformin 500mg BID, Levothyroxine 75mcg daily, Ibuprofen 400mg PRN for arthritis pain (takes 3-4 times/week).Allergies: NKDA.
Signs and Symptoms (S&S) Observed:
- Subjective: Reported forgetfulness (husband), “a little foggy” (patient), recent near falls (husband), misplacing items (husband), decreased appetite (husband).
- Objective:
- General: Thin but well-nourished, appears her stated age, oriented to person and place, but slightly hesitant with date. Sits comfortably in chair.
- Vitals: BP 138/78, HR 72, RR 16, Temp 97.6°F (36.4°C), O2 Sat 98% on room air.
- Cognitive Assessment (MOCA score): 20/30 (indicates mild cognitive impairment, but must be interpreted carefully with other findings). Difficulties noted in delayed recall and visuospatial tasks.
- Neurological:
- Cranial Nerves: Intact II-XII.
- Motor: 5/5 strength bilaterally in all four extremities.
- Sensory: Intact light touch, pain, temperature, vibration, and proprioception.
- Reflexes: 2+ and symmetric throughout.
- Gait: Shuffling gait noted, slightly wide-based. Positive Romberg test (slight sway with eyes closed). Able to walk heel-to-toe with difficulty.
- Other relevant findings: Skin turgor good, mucous membranes moist. No signs of infection.
Assessment: The patient presents with subacute onset of cognitive changes and gait instability. These symptoms are concerning given her age and suggest a need for thorough investigation to rule out reversible causes before considering primary neurodegenerative processes. Her current medication list includes Ibuprofen, which can have cognitive side effects in the elderly, and potential interactions or cumulative effects should be considered. The low temperature (97.6°F) could be normal for an older adult but should be noted.
Plan of Care:
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Diagnostics:
- Complete Blood Count (CBC): To rule out anemia or infection.
- Comprehensive Metabolic Panel (CMP): To assess kidney function, liver function, and electrolytes (sodium, glucose, calcium abnormalities can affect cognition).
- Thyroid Stimulating Hormone (TSH): To rule out hypothyroidism as a cause of cognitive and gait changes (already on Levothyroxine, but check levels).
- Vitamin B12 level: To rule out B12 deficiency, a reversible cause of cognitive impairment.
- Urinalysis (UA) with culture & sensitivity (C&S): To rule out asymptomatic urinary tract infection (UTI), a common cause of acute confusion in the elderly.
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