Name
Gabriel Kiles
DOB
26/03/1948 (68 years)
Occupation
Retired Baker
History
I was admitted with a stroke affecting my swallowing, manual dexterity and if directly asked, left me incontinent of urine. If directly asked, I have more trouble with large pieces of solid food. I have decreased grip strength and movement in my dominant right hand. I am being discharged on a lot of medication, however shouldn't have trouble taking it. 

 I am concerned that I will not be able to easily get out of bed, getting ready in the morning due to difficulties with things like brushing my teeth or do the cooking. However I am able to walk around and can do shopping online. I have no trouble with any other activities. I am concerned I will choke on food and die.
Past Medical History
Diabetes, High blood pressure & cholesterol
Drug History
Metformin, Amlodipine, Ramipril, Atorvastatin. Newly started: Aspirin and Clopidogrel. 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 friends that are still alive or any family. Very helpful neighbours that could potentially help him occasionally with some tasks.




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