Patient Details

69 year old man

Current medical history

  • Fracture neck of femur 2 years ago
  • Dementia – mixed Alzheimer’s disease / alcohol abuse
  • Ex-Smoker
  • Frequent Falls

Results

  • BP 120/84 mmHg
  • eGFR  > 60ml/min
  • FBC and U+E normal
  • MMSE score 14

Current Medication [stable since admission]

  • Trazodone 150 mg at night
  • Thiamine 50 mg three times daily
  • Bendroflumethiazide 2.5 mg once daily
  • Tramadol 50 mg four times daily
  • Cetirizine 10 mg once daily
  • Amisulpride 100 mg twice daily
  • Diprobase cream (as required)
  • Fucibet cream topically twice daily

Current Function

69 year old man who has been a care home resident  for 2 years. Long term heavy alcohol use in the past. Developed dementia exacerbated by alcohol related brain damage. Fell at home leading to fractured hip. Very confused and distressed post-surgery. When settled, unable to manage at home post-fracture and transferred to care home.  Lacked capacity at time of admission, however with additional support this has improved.

Assistance of two carers required for transfer to chair. Patient falls frequently as he attempts to mobilise unaided. Conversation is confused and occasional verbal aggression,  patient also has poor short term memory. Prompting is required to ensure that he eats and drinks. Spends most of the day sleeping in his chair. Sleeps well at night.  Over the last 12 months has developed ankle swelling and shortness of breath.

 

Most Recent Consultations

Communication is sometimes difficult due to cognitive impairment. He has had three consultations in the last 6 months. One was for a chest infection for which he was prescribed an antibiotic. A second consultation for review following a fall, only minor bruising was noted on examination. The most recent consultation was regarding concern over leg oedema. There is minimal contact with the family.