Geriatric Assessment-Mr Smith 65 Year Old Male

When engaging with Mr. Smith, conducting a thorough and patient-focused geriatric assessment that encompasses his medical, psychological, and social requirements is imperative. Due to his recent fall and alcohol consumption patterns, a comprehensive assessment is required to safeguard his safety, overall health, and well-being (Sum et al., 2022). To begin with, gathering a comprehensive medical history encompassing chronic ailments, prescribed medications, and known allergies is imperative. This data will shed light on underlying factors influencing his decline and overall well-being. The patient’s alcohol-induced fall and regular daily drinking raise concerns regarding potential alcohol-related problems.

Diagnostics

Considering the fall and the need for stitches, a head CT scan may be necessary to rule out significant head injury or bleeding inside the skull (Appeadu & Bordoni, 2022). Blood tests, including liver function tests and complete blood counts, provide valuable insights into the impact of alcohol on health, potential vitamin deficiencies, and underlying medical conditions. In addition, considering Mr Smith’s acknowledgement of daily alcohol consumption and its connection to his fall, an evaluation for alcohol use disorder is imperative. This could entail employing standardized questionnaires or interviews to assess the magnitude of his alcohol consumption and its impact on his well-being.

The Treatment Plan

Regarding the fall incident, the response relies on the CT scan and physical examination results. Depending on the results, the treatment for the patient’s head injury will involve careful wound care and continuous monitoring for signs of concussion or intracranial bleeding. Also, given the significant impact of his habitual alcohol intake on the incident, addressing and mitigating his alcohol consumption is paramount (Appeadu & Bordoni, 2022). This involves counselling, behaviour-focused interventions, and a possible referral to an addiction medicine specialist.

Acknowledging the crucial role of his spouse and her active participation in discussions regarding treatment, lifestyle changes, and practical support strategies is also essential. Considering Mr. Smith’s future health and well-being, this incident highlights the importance of future planning, including discussions on driving safety, advanced directives, and the potential need for assisted living.

References

Appeadu, M. K., & Bordoni, B. (2022). Falls and fall prevention in the elderly. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK560761/#:~:text=Risk%20factors%20for%20falls%20in

Sum, G., Nicholas, S. O., Nai, Z. L., Ding, Y. Y., & Tan, W. S. (2022). Health outcomes and implementation barriers and facilitators of comprehensive geriatric assessment in community settings: a systematic integrative review [PROSPERO registration no.: CRD42021229953]. BMC Geriatrics, 22(1), 379. https://doi.org/10.1186/s12877-022-03024-4

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Question

Mr Smith is a 65-year-old male who is accompanied by his wife to your clinic. He is following up after an ER visit for a fall at home that resulted in 6 stitches to his forehead. He admits that he had a few drinks that night before tripping over his dog. His wife adds that he has “a few drinks” every night.