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
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1

Confirms name & age of patient
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1

Explains reason for consultation & builds rapport
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1

Gains consent
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1

Asks what brought them to hospital
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1

Asks about treatment received and long term treatment (if required)
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1

Checks understanding of admission and long term treatment
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1

Checks if patient is aware how to prevent recurrence
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1

Asks open question about their concerns going home (regarding condition and resuming day to day activities)
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1

Establishes home environment (type of accommodation, stairs)
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1

Establishes baseline activity level and support required (what they needed help with and from whom they received it)
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1

Establishes who lives at home and who is able to offer support if required
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1

Explains that they will run through daily activities to identify any potential problems and offer solutions
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1

Issues with sitting up in bed and standing (solution: bed rails)
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1

Issues with walking around house (solutions: stick/frame/wheelchair)
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1

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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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)
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1

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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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)
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1

Issues with shopping (solutions: online shopping and delivery, support from neighbours/family/carers, meals on wheels)
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1

Issues with taking medication (solutions: nurse to explain administration, dosette box, district nurse to assist in administration)
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1

Issues with incontinence (solutions: input from continence nurse, commode, incontinence pads)
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1

Offer to discuss social care needs with rest of multidisciplinary team
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1

Offer follow up (or suggest appointment with GP) if additional needs arise
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1

Checks understanding at each stage
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1

Provides opportunity at each stage for questions
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1

Explores and responds to ideas
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1

Explores and responds to concerns
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1

Explores and responds to expectations
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1

Shows empathy
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1

Avoids jargon
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1

Summarises back to patient
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1

Thanks patient
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1

Patient global score
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1
2