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Name
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Marcus Avraham
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DOB
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26/03/1943 (73 years)
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Occupation
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Retired Librarian
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History
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I have prostate cancer and have at least 2 years left. It is
managed with hormone therapy and I have had radiotherapy to the metastases in
my back.
I have had increasing shoulder and upper back pain which is
there continuously and which wakes me up at night. It is a dull to sharp pain
that is worsened on movement. It doesn't move anywhere and nothing helps with
the pain, despite trying regular paracetamol. It is 8/10 in severity. I have
no other symptoms. I am worried this means my prostate cancer is more
aggressive and it will mean I have less time to live.
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Past Medical History
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Hypertensive, Hypercholesterolaemia
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Drug History
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Amlodipine, Atorvastatin, Paracetamol. No allergies.
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Family History
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Nil
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Social History
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I have little support as I live alone and my children live too
far to help. I find it difficult to shower, get ready in the morning and
increasingly difficult to cook. I am in severe need of help. I am not spiritual.
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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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Briefly clarifies long
term diagnosis, management and prognosis
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0
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1
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Asks open question
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0
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1
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Site of pain
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0
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1
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Onset and time course of
pain
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0
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1
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Character of pain
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0
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1
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Radiation of pain
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0
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1
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Exacerbating/alleviating
factors of pain
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0
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1
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Severity of pain
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0
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1
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Screens for breathlessness
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0
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1
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Screens for constipation
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0
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1
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Screens for anorexia
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0
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1
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Screens for nausea &
vomiting
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0
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1
|
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Elicits past medical
history
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0
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1
|
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Elicits drug history
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0
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1
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Checks for allergies
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0
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1
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Establishes what patient
has tried so far for symptoms
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0
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1
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Discusses pain management
(massage/TENS, analgesic ladder, adjuvants)
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0
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1
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Suggests to patient that
they may need further tests to identify cause (giving examples)
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0
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1
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Asks about spiritual or
religious beliefs and whether support is wanted
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0
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1
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Asks about social support
and mentions services available (e.g. McMillan)
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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
|
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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