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Name
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Ian Nelson
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DOB
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20/11/1944 (71 years)
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Occupation
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Retired Composer
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History
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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.
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Past Medical History
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Diabetes. Distal neuropathy affecting feet only.
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Drug History
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Metformin, Gliclazide, Insulin twice per day. Newly
started: Codeine and Paracetamol. No allergies
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Family History
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Father had Type 2 diabetes
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Social History
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Non-smoker. Non-drinker. Lives alone but has a sister who
does not live too far. Has a son and daughter who live abroad.
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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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