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Name
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Ryan Clarkson
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DOB
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24/02/1948 (68 years)
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Occupation
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Retired Stockbroker
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History
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I was admitted with an
exacerbation of my COPD and was treated with some nebulisers and tablets.
They have added a new steroid inhaler and am unsure how to use it. I was very
frightened with the experience, in particular the very tight fitting oxygen
mask and would like someone to explain how to stop this happening again.
I
was quite independent at home prior to the admission and cannot think of any
help I might require at home. On direct questioning, I realise that my
breathlessness has been much worse and I think shopping and cooking will be
very difficult!
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Past Medical History
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COPD for last 3 years.
Acid reflux for many years.
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Drug History
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Salbutamol, tiotropium
and ipratropium inhalers. Have rescue pack at home for exacerbations.
Omeprazole. No allergies
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Family History
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Nil
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Social History
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Ex-smoker. Non-drinker.
Lives alone but has very helpful neighbours who currently help with shopping
occasionally. Will be unable to see close friends who he sees at the pub
every few days due to limitation on walking distance. Unable to drive.
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Introduces yourself
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0
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1
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Confirms name & age
of patient
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0
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1
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Explains reason for
consultation & builds rapport
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0
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1
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Gains consent
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0
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1
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Asks what brought them
to hospital
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0
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1
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Asks about treatment
received and long term treatment (if required)
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0
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1
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Checks understanding of
admission and long term treatment
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0
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1
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Checks if patient is
aware how to prevent recurrence
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0
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1
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Asks open question
about their concerns going home (regarding condition and resuming day to day
activities)
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0
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1
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Establishes home
environment (type of accommodation, stairs)
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0
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1
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Establishes baseline
activity level and support required (what they needed help with and from whom
they received it)
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0
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1
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Establishes who lives
at home and who is able to offer support if required
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0
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1
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Explains that they will
run through daily activities to identify any potential problems and offer
solutions
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0
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1
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Issues with sitting up
in bed and standing (solution: bed rails)
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0
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1
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Issues with walking
around house (solutions: stick/frame/wheelchair)
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0
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1
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Issues with going to
toilet/showering (solutions: bedside light, toilet/shower rails, seat in
shower, slip proof mat, accessible shower, private/NHS carers)
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0
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1
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Issues with cleaning
teeth/brushing hair/dressing and if applicable shaving/applying make-up
(solutions: larger or longer handles, support from family, private/NHS
carers)
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0
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1
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Issues with walking
up/down stairs (solutions: rails on stairs, ground floor facilities, support
from family/private/NHS carers, stair lift)
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0
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1
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Issues with cooking
meals and eating (solutions: SALT and dietitian assistance, simpler meals,
easy to use cookware and cutlery, support from family/carers, meals on
wheels)
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0
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1
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Issues with shopping
(solutions: online shopping and delivery, support from
neighbours/family/carers, meals on wheels)
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0
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1
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Issues with taking
medication (solutions: nurse to explain administration, dosette box, district
nurse to assist in administration)
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0
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1
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Issues with
incontinence (solutions: input from continence nurse, commode, incontinence
pads)
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0
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1
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Offer to discuss social
care needs with rest of multidisciplinary team
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0
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1
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Offer follow up (or
suggest appointment with GP) if additional needs arise
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0
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1
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Checks understanding at
each stage
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0
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1
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Provides opportunity at
each stage for questions
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0
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1
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Explores and responds
to ideas
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0
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1
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Explores and responds
to concerns
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0
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1
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Explores and responds
to expectations
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0
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1
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Shows empathy
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0
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1
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Avoids jargon
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0
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1
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Summarises back to
patient
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0
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1
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Thanks patient
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0
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1
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Patient global score
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0
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1
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2
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