Name
|
Ian Nelson
|
DOB
|
20/11/1944 (71 years)
|
Occupation
|
Retired Composer
|
History
|
I was admitted after I injured my wrist after a fall. I
was treated with a splint by the orthopaedic team. They have discharged me on
some pain medication (codeine and paracetamol) which have made me feel
slightly drowsy. If directly asked, I fell when going to the toilet at night
to urinate which I do frequently. I am not aware of any prostrate problems.
I
feel anxious about returning home as I have lost my confidence having fallen.
On direct questioning of activities of daily living, I realise that getting
ready in the morning, shopping and cooking will be more difficult. I am also
worried about falling in the toilet again.
|
Past Medical History
|
Diabetes. Distal neuropathy affecting feet only.
|
Drug History
|
Metformin, Gliclazide, Insulin twice per day. Newly
started: Codeine and Paracetamol. No allergies
|
Family History
|
Father had Type 2 diabetes
|
Social History
|
Non-smoker. Non-drinker. Lives alone but has a sister who
does not live too far. Has a son and daughter who live abroad.
|
Introduces yourself
|
0
|
1
|
|
Confirms name & age
of patient
|
0
|
1
|
|
Explains reason for
consultation & builds rapport
|
0
|
1
|
|
Gains consent
|
0
|
1
|
|
Asks what brought them
to hospital
|
0
|
1
|
|
Asks about treatment
received and long term treatment (if required)
|
0
|
1
|
|
Checks understanding of
admission and long term treatment
|
0
|
1
|
|
Checks if patient is
aware how to prevent recurrence
|
0
|
1
|
|
Asks open question
about their concerns going home (regarding condition and resuming day to day
activities)
|
0
|
1
|
|
Establishes home
environment (type of accommodation, stairs)
|
0
|
1
|
|
Establishes baseline
activity level and support required (what they needed help with and from whom
they received it)
|
0
|
1
|
|
Establishes who lives
at home and who is able to offer support if required
|
0
|
1
|
|
Explains that they will
run through daily activities to identify any potential problems and offer
solutions
|
0
|
1
|
|
Issues with sitting up
in bed and standing (solution: bed rails)
|
0
|
1
|
|
Issues with walking
around house (solutions: stick/frame/wheelchair)
|
0
|
1
|
|
Issues with going to
toilet/showering (solutions: bedside light, toilet/shower rails, seat in
shower, slip proof mat, accessible shower, private/NHS carers)
|
0
|
1
|
|
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)
|
0
|
1
|
|
Issues with walking
up/down stairs (solutions: rails on stairs, ground floor facilities, support
from family/private/NHS carers, stair lift)
|
0
|
1
|
|
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)
|
0
|
1
|
|
Issues with shopping
(solutions: online shopping and delivery, support from
neighbours/family/carers, meals on wheels)
|
0
|
1
|
|
Issues with taking
medication (solutions: nurse to explain administration, dosette box, district
nurse to assist in administration)
|
0
|
1
|
|
Issues with
incontinence (solutions: input from continence nurse, commode, incontinence
pads)
|
0
|
1
|
|
Offer to discuss social
care needs with rest of multidisciplinary team
|
0
|
1
|
|
Offer follow up (or
suggest appointment with GP) if additional needs arise
|
0
|
1
|
|
Checks understanding at
each stage
|
0
|
1
|
|
Provides opportunity at
each stage for questions
|
0
|
1
|
|
Explores and responds
to ideas
|
0
|
1
|
|
Explores and responds
to concerns
|
0
|
1
|
|
Explores and responds
to expectations
|
0
|
1
|
|
Shows empathy
|
0
|
1
|
|
Avoids jargon
|
0
|
1
|
|
Summarises back to
patient
|
0
|
1
|
|
Thanks patient
|
0
|
1
|
|
Patient global score
|
0
|
1
|
2
|