Driving License

HISTORY:

Presents for a driving license assessment

Required because of: ‍agehealth conditionnecessity for work ‍

Type of license: ‍

Current complaints: ‍none



Past medical history: ‍unremarkable

‍diabetes

‍coronary artery disease

‍congestive heart disease

‍chronic obstructive pulmonary disease

‍sleep apnea

‍seizures

‍vision impairment

‍hearing impairment

‍mobility impairment

‍cognitive impairment

‍ADHD

‍mental health issue

‍substance abuse issue



Medications: ‍ ‍none, ‍sedatives

Adverse effects: ‍ ‍none



Social history:

Smoking: ‍neversmokerformer smoker, ‍ pack-years

Alcohol: ‍nonesociallyexcessive, ‍ drinks per ‍dayweek

Recreational drugs: ‍none ‍cannabis, ‍IVDU



EXAM:

General appearance: ‍well-appearing

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Eyes: -R: ‍normal, -L: ‍normal, ‍

Ears: -R: ‍normal, -L: ‍normal

Neck: ‍normallymphadenopathy

Heart: ‍RRR, ‍normal S1 and S2

Lungs: ‍clearabnormal sounds, ‍retractions

Abdomen: ‍softsemi-softtense, ‍non-tender ‍, ‍non-distended, ‍

Musculoskeletal: joints ‍ ‍normal, ‍no limited ROM

Neurologic: cranial nerves ‍normal, strength ‍5/5 throughout, sensation ‍normal, reflexes ‍2+ throughout, cerebellar function ‍normal, gait ‍stable

Mental status: ‍alert, ‍oriented, speech ‍clear, mood ‍normal, thought process ‍organized, ‍no suicidal ideation, judgment ‍good



ASSESSMENT:

‍Normal assessment ‍likelysuspectedpossible



PLAN:

- Vision test

- Hearing test

- Cognitive assessment

- Reassessment of medications that may impair driving

- Referral to optometrist

- Referral to audiologist

- Referral to neurologist

- Referral to occupational therapist

- Driving license form filled

- Follow-up in ‍ ‍monthsyears