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Rock Street, San Francisco

GP reflective Report
Dean Wright
13359226

A) Patient history

Presenting Complaints
Mrs. H. is an 88 year-old woman living indepentently who, on visit to the patient’s home, present with:
1. Nausea on morning of interview. No vomiting, diarrhoea, night sweats, dysuria or abdominal pain.
2. Worsening pain in hand and knee joints x 2/12 despite initial analgesia.

Medical History
Type 2 Diabetes Mellitus:
Diverticular Disease
Osteoarthritis – knee joints and hand digits worst affected
Atrial Fibrillation
Osteopenia
Hypothyroidism
Ischaemic Heart Disease
Chronic Constipation

Medications
As described in ‘Medication Review’ below.

Surgical History
1989 – Oophorectomy – complicated by formation of abscess
1989 -2 x laparotomy and drainage of abscess in response to complicated oophorectomy
2002 – Bilateral Total Hip Replacement. Uncomplicated

Family history
Son has atrial fibrillation
No other mentionable family history

Social History
Husband died in 1992 – has been living alone ever since
Lives alone in cottage in rural area beside farmhouse (where she previously resided until 2002) 200 metres away from son and daughter-in-law.
Has two adult children that are well.
Support – daily communication with son and daughter-in-law.
Gets home help once a week to clean her house.

Mrs H reports that her mood is generally ‘very good’ however she feels she has become more isolated since she stopped driving one year ago.
Geriatric Depression Scale: 3. (

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