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criteria 7. Long term patient care

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  2. A 57 widow with Rhuematoid arthritis. I also looked after her late husband who was diagnosed with terminal cancer lung.
    She used to work as a shop assistant before she took an early retirement due to her Rheumatoid disease
    She lives in a three bedrooms house, she inherited a good amount of money after her husband’s death and she spent some on the house equipments and alterations to help her cope at home
    She has a son who lives in away, and a step daughter who lives not very far, and she keeps good relations with both.
    When I first met with Mrs N, she was recently diagnosed with Seropositive Rheumatoid arthritis. She was started on Sulphasalazine by Rheumatologist and she came to the surgery to start on the routine blood test follow up and she came for consultation to ask for a sick note.
    Her past medical history also included
    High blood pressure
    Type II Diabetes mellitus
    And mild depression
    During my consultation with her I established a good rapport, which helped me to ask her in details about her feeling. In DHSM-IV (diagnostic and statistical manual) questionnaire she scored moderate to high for depression. I offered her help about that, and she opted to come again and discuss in more details. I also touched the area of coping at work, and at home. Her husband was fit and well at that time. We also talked in details about the monitoring of Sulphsalazine and the red flag symptoms such as (unexplained bleeding, bruising, sore throat, fever or malaise ) that she needed to report to us if they happen.
    Consultation 2 ( 20/01/2009 )
    Mrs N came in two weeks time of her initial consultation complaining of cough and feeling chesty, also her depression symptoms were even worse. There were no sore throat symptoms, and her examination showed upper respiratory tract infection signs. I had a CBT (cognitive behavioral Therapy) introductory chat with her. I offered her counseling, and she agreed to go for it. I also offered her antibiotics which she opted for. She was not still able to go back to work so another sick note for further two weeks issued. She reported no symptoms of side effects of Sulphasalazine, however her pain was not brilliantly controlled. I offered her use of co-codamol as on need basis. I asked her to come again in two weeks time for a review. In this consultation I talked with Mrs N about her smoking habit and the need to stop. She was pre-contemplator. She wasn’t prepared to do anything about it. I asked her to start thinking about her lungs’ future, and to look at how it would be in 10 or 20 years time, if she carried on smoking as she was. She mentioned that her husband smokes heavily too, that’s why she didn’t think about stopping.
    As it was rather lengthy consultation, I asked her to book appointment with the health care assistant to do routine blood test.
    Consultation 3 ( 16/02/2009)
    Mrs N came to see me as she was feeling of very low mood; she broke into tears in the consultation as her husband was recently diagnosed with lung cancer. She also reported worsening in her joint pains. It was rather difficult consultation as Mrs N was shocked with her husband diagnosis. She counted on him to help her with her illness; she felt that things went all wrong. She didn’t want to express her very low feelings in front of her husband. She wanted to put on a brave face to help her husband. We had a long chat together and I mentioned to her the possible help of alliance services to her condition as well as to her husband.
    I saw her husband in next consultation and Mrs N attended her husband’s consultation. She was very positive during her husbands consultation, which assured me as well.
    Home visit ( 26/02/2009)
    It was mainly to Mrs N’s husband, for pain control and possible chest infection.
    I needed to mention this visit here because during the home consultation to her husband I felt that Mrs N started to have a 180 degree change in her attitude, and in her way of looking to things. She started to be very positive in her thoughts all wanting to be of good help to her husband. She didn’t have complaint at that meeting, she asked for issuing a repeat prescription to her usual pain killers, and inquired about next chronic disease clinic follow up appointment for her diabetes. Which I passed on to the receptionist to deal with.
    Consultation ( 30/3/2009 )
    Mrs N was just seen in the rheumatology out patient clinic a week prior to this consultation. She asked for a renewal of her sick note, with viewing of complete retirement. She was 56years old. She had had a bone density scan which showed osteoporosis. Mrs N accepted that very well, and she though this diagnosis added to what she was thinking of to just retire of work and spend more of her time with her husband to look after him. This consultation went very well. Her pain was more or less controlled. Her mood wasn’t that bad when I asked her, however when we talked about her husband she started to cry. I felt that she is managing well overall. Carers of her husband were started to go twice a day to help him in and out of bed.
    A sick note of three month was issued to her for rheumatoid arthritis and back pain.

    Rheumatology team
    District nurse
    Occupational therapy was involved for assessment of home needs, fitting a stair left was done
    Because I know the family very well for over than a two years, when I looked after this lady’s husband during his terminal illness, I got a good ground of communication with this patient.
    I keep good contact with rheumatology team, there is a direct phone number I can ring to chat with the rheumatology nurse about this lady
    I monitor the blood results
    The system for repeat prescription in the practice allows me to monitor her medication intake and level of pain control
    I get feed back from district nurses about the patient and pass to them my views and medical input

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