Name
Rajesh Shah
DOB
18/01/1959 (57 years)
Occupation
Financial Advisor
History
I was admitted with severe chest pain, shortness of breath and feeling sweaty. I was quickly diagnosed of a heart attack and treated with stents in two of my arteries. I am being discharged on lots of medication but am unsure of the exact names. I will find difficult to remember which ones to take. I insist on some NHS carers to give me my tablets 3 times per day. If directly asked, I actually want them for company as I am quite lonely since my wife died. Otherwise I am quite sure I will manage with everything. I want to quit smoking and would like some advice.
Past Medical History
Diabetes, High blood pressure & cholesterol
Drug History
Metformin, Amlodipine, Ramipril, Atorvastatin. Newly started: Aspirin, Clopidogrel, Bisoprolol and GTN. No allergies
Family History
Both parents had heart attack when they were in their early 50s. Also both had high blood pressure
Social History
Smoker and drinks alcohol occasionally. Lives alone and has no support network. Works frequently from home.




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