Medicare Initial Preventive Physical Examination Report for a 70-Year-Old Patient Essay

Purpose of Report

The “Welcome to Medicare” visit is officially known as the Initial Preventive Physical Examination (IPPE). During this visit, a physician reviews a patient’s medical and social histories regarding health concerns. This report is a “Welcome to Medicare “write-up of a 70-year-old male that includes a review of the patient’s medical and social history, a review of the patient’s potential for depression and mood disorders, physical examination, and end-of-life planning. Other items that will be included in the report include education and counsel depending on the results of physical examination and preventative services.

Review of the Medical and Social History

The client is a 70-year-old male whose physical movement is limited by age. Despite his age, the patient occasionally goes to the gym at least two times a month. The patient’s Past Medical History (PMH) is long and goes back several decades due to his advanced age. However, other than seasonal diseases, the client does not have a history of complex medical conditions such as chronic kidney disease, ulcerative colitis, hypertension, or heart failure with preserved ejection fraction.

The patient’s Past Surgical History (PSH) is brief, as he has only had minor surgery to remove a clot in his head, repair a broken right limb, and repair a fractured nose. The patient currently takes type-2 diabetes medication and occasionally takes medication to control high blood pressure.

He has no history of substance abuse, and his diet is balanced with all the elements he needs at his age. The patient did, however, disclose that he smoked cigarettes into his late 40s before quitting due to a doctor’s recommendation. When reviewing his Family History (FHx), it was established that some members of his extended family have pseudo-hereditary conditions such as substance abuse problems, type-1 diabetes, and anemia.

Review of Risks for Depression or Other Mood Disorders

To assess the patient’s depression and other mood disorders, two screening tools, namely the Patient Health Questionnaire (PHQ) and the Depression, Anxiety, and Stress Scale (DASS-22), were used. PHQ assesses the severity of depression in clinical and community settings. DASS-22 assesses depression and anxiety’s negative emotions and stress.

PHQ results indicated the patient had depressive symptoms, corresponding to a relatively higher PHQ score. Despite the higher score, the patient was assessed to be at risk of depression but had not closed the threshold of a major depressive disorder. DASS-21 assesses the emotional states of depression and other disorders. The results may be normal, moderate, or severe. The patient’s score showed that his emotional state was normal.

The patient was required to fill in the Mood Disorder Questionnaire (MDQ) to assess other mood disorders. This questionnaire assesses whether a patient has other mood disorders, such as bipolar disorder. The results of the MDQ conclusively showed that the patient did not have any other mood disorder other than mild depression, which was diagnosed using PHQ and confirmed by DASS-21.

Review of Functional Ability and Level of Safety

This review assesses the patient’s daily living activities (ADLs), fall risks, hearing impairments, and home safety. The Center for Disease and Control’s (CDC) self-rated Fall Risk Questionnaire (self-rate FRQ) was used to assess the patient’s fall risk (Kitcharanant et al., 2020). The risks of the patient falling were assessed to be low based on the score of his self-rate FRQ. Despite his advanced age, the client was engaged in some physical activities, including occasionally going to the gym. The irregular intervals of his visits to the gym diminished his risk of falling.

Several tests were administered to assess whether the patient had any hearing impairment. These tests included the HHIE-S Questionnaire test and the self-perception tests. The results from the tests and the questionnaire indicated the patient has no hearing impairment.

Home safety was assessed by asking the patient some questions against a checklist. On the checklist, several items are included that help identify whether the patient faces any physical risks at his place or residence (Davis & Davis, 2022). From the assessment, the client does not face any immediate physical safety risks as his dwelling place meets the criteria of a safe environment for an older adult.

Exam

This section requires the patient’s physical examination, which includes height (Ht), weight (Wt), and body mass index. The patient was six foot two inches and 180 pounds in weight. Taking his height and weight into account, the patient had a BMI of 23.2. This means that the patient’s weight is normal and is not at risk of being obese or being affected by other weight-related health issues.

End-of-Life Planning

The patient had a verbal end-of-life planning where he outlined instructions on what would happen to him if he were to get an injury or an illness that would incapacitate him to the point of being unable to make healthcare decisions. Other than verbal instructions, the patient had written instructions on how he would want to be taken care of in case of his death or medical incapacitation that would render him unable to make healthcare decisions. Additionally, the beneficiary’s wishes expressed in the advance directive would be followed in case of incapacitation.

Educating, Counseling, and Refering Based on Previous Components

After assessing the patient’s previous medical and social history, the patient is advised to take several steps to maintain his health and prevent other complex medical conditions. The client has had several minor surgeries throughout his life. These are likely to cause some pain in the future. If he feels pain he cannot handle, the client is advised to seek immediate medical help and not self-medicate.

Additionally, the patient is advised to continue with his type-2 diabetes medication to maintain his blood sugar at normal levels. The patient was also advised to continue monitoring his blood pressure and take medication as recommended by a physician.

Further, the patient was at no risk of type-1 diabetes despite family members having it. His advanced age and the fact that he was already managing type-2 diabetes meant that he could not contract type-1 diabetes. However, his weight was assessed to be low based on his height. Thus, he should change his diet to gain some weight, which would ensure an increase in his BMI that matches his height.

Additionally, as he advances through his age, the patient should make further changes to his residence to ensure that added safety. This recommendation is based on the fact that as he advances in age, he is likely to fall if he does not take recommended actions for physical safety. The patient had no hearing impairment, and it was recommended that he avoid places with excessive noise or wear hearing protection in case he comes up to an area with excessive noise.

Further, the client was advised to make going to the gym a habit. Exercising is suitable for people his age whether or not they have chronic diseases or not. Some of these chronic conditions improve with exercise. Finally, the patient exhibited symptoms of mild depression, which, if left untreated, could lead to major depressive disorder. The patient was advised to engage in more exercises to prevent the mild depression from worsening and to interact with more people when he gets the chance. These actions would ensure that his symptoms do not exacerbate a situation where major depressive disorder kicks in.

Educating, Counseling, and Refering for Preventive Services

As a 70-year-old adult, the patient is more likely to be hospitalized than most younger people. Consequently, there are active steps that he could take to prevent or delay his potential hospitalization. These steps include monitoring an individual’s diabetes, cholesterol levels, and blood pressure.

Further, the patient should develop an exercise routine, always eat healthily, treat and manage mild depression, and reduce his consumption of sugary foods. Due to a history of substance abuse in his family, he should avoid taking medication with opioids and disclose this family’s history to a physician when appropriate.

The patient should also ensure that he is up-to-date with all vaccinations, including but not limited to COVID-19. At his age, he is susceptible to COVID-19 complications, which would be disastrous for his respiratory system. The patient should also undergo regular screening for chronic conditions such as kidney disease, ulcerative colitis, hypertension, etc. The screening could be scheduled at annual or semi-annual intervals to ensure that any chronic conditions are detected before they escalate to more significant problems that could threaten the patient’s life.

References

Kitcharanant, N., Vanitcharoenkul, E., & Unnanuntana, A. (2020). Validity and reliability of the self-rated fall risk questionnaire in older adults with osteoporosis. BMC Musculoskeletal Disorders, 21(1). Web.

Davis, K., & Davis, D. (2022). Home Safety Techniques – StatPearls – NCBI Bookshelf. National Library of Medicine. Web.