Driving License

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents for a driving license assessment

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



Smoking: ‍neversmokerformer smoker, ‍ pack-years

Alcohol: ‍nonesociallyexcessive, ‍ drinks per ‍dayweek

Recreational drugs: ‍none ‍cannabis, ‍IVDU





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

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

Eyes: conjunctiva/sclera ‍normal, lids/lashes ‍normal, cornea ‍intact, ‍PERRL, extraocular movements ‍intact, OD 20/‍, OS 20/‍

Ears: tympanic membranes ‍normal ‍, auditory canal ‍ on ‍rightleft, hearing ‍intact

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍

Musculoskeletal: joints ‍ ‍normal, ‍limited ROM

Neurologic: cranial nerves ‍intact, strength ‍intact 5/5, sensation ‍intact, reflexes ‍intact 2+, cerebellar function ‍intact, gait ‍steady

Mental status: ‍alert, ‍oriented, speech ‍clear, mood ‍normal, thought ‍organized, ‍suicidal ideation, judgment ‍good





ASSESSMENT:

‍Normal assessment ‍likelysuspectedpossible





PLAN:

Investigations:

- Vision test

- Hearing test

- Cognitive assessment

Treatments:

- Reassessment of medications that may impair driving

Further care:

- Referral to optometrist

- Referral to audiologist

- Referral to neurologist

- Referral to occupational therapist

- Driving license form filled

- Follow-up in ‍ ‍monthsyears