FREMANTLE HOSPITAL AND HEALTH SERVICE

INTEGRATED MEDICAL RECORDSSURNAME:   Davies              URMN:    M625197           SEX:      M      FORENAMES:                 Justin          BIRTHDATE:       18/04/1965               ADDRESS: 10/74 Lincoln Street, Highgate 6015  
  
20/05/present dateMedical admission:
1100hrs55 year old male
 Presents with painful R foot ulcer
 PMH: Colorectal Ca
 Dx 4 weeks
 Yet to commence treatment
             T2DM
 Dx 4 weeks ago
 Metformin monotherapy
 HbA1c 7-8%
           Peripheral Neuropathy
 ? Related to T2DM. No cause noted
           HTN
  Presenting complaint
 3/7 worsening pain and swlling R foot
 Known wound on plantar aspect of foot, unsure of progress
 No systemic symptoms of fevers, chills, nausea
 MEDS: metformin 500mg twice daily
          Ramipril 2.5mg
 All: NKDA
 O/E:  BP   145/80    HR: 75 regular             RR: 20            SATS: 98% RA
 Heart sounds normal
 Absent sensation to monofilament on plantar aspect of feet bilaterally. No motor deficits.
 Neurological exam otherwise NAD.
 Wound: R plantar aspect- 2 x 2 cms punched out ulcer under 1st MTP. No Pus.
 Surrounding cellulitis
 Issues: Neuropathic ulcer R foot
 Neuropathy out of keeping with early T2DM
 Plan: Add empagliflozin for diabetic control
 Commence IV augmentin for infection
 Podiatry R/V
 Neurologist review re: peripheral neuropathy
 Urine ACR- evaluate for diabetic nephropathy
 A/H team review and discharge planning
 ————————————————————————-C. Johns #2323—————————-
20/05/present dateNursing: New patient admitted to ward, Bed 06 at 0945hrs. Mr Davies presents with a right
1130hrsfoot, stage 4 pressure area around head of 1st metatarsal (plantar). Wound management
 plan completed. Mepilex dressing in place over wound. Daily dressing changes noted.
 History of obesity (160kg) , diagnosis of bowel cancer and T2DM 4/52 ago, Peripheral
 neuropathy, Hypertension. Nil known allergies. Justin scheduled to commence daily
 pre-surgical radiation therapy in 2/52 as an outpatient in the Radiation Oncolgy Unit. Will
 receive concurrent chemotherapy via continuous infusion pump over the course of his
 radiation therapy. Message left with oncolgy re: Mx plan due to current inpatient status.
 BP:145/80mmHg. HR: 75bpm.  RR: 20bpm.  O2 sats 98% RA (Room air)
 Neuro: Presents as alert and orientated ? Withdrawn *** Complaints of tinging in lower
 limbs during full hoist transfer onto bed. Sides up, call bell in reach. Falls risk assessment
 completed. Lower limbs warm to touch. Right lower limb noted to be hot, swollen and red.
 Respiration: Respiratoy assessment NAD. Gastro: NAD. IV cannula in situ (dorsum R hand)
 Patient states nil issues with eating once set up on ward. Full assistance with bowel
 Management. Pressure area Risk Assessment updated. Psychosocial: Separated, lives alone
 Next of kin (NOK) notified of transfer to ward. Equipment: urinal at bedside.
 For AH review, wound management, discharge planning—————-S.Thomas (RN)
20/05/present dateOccupational therapy:  Initial contact and assessment with Mr Davies who was admitted
1150hrswith stage 4 pressure area on plantar aspect of right foot (1st MTP). Diagnosed with bowel
 cancer and T2DM 4/52.   Sitting up in electric hospital bed on OT arrival. Introduced role of 
 Occupational Therapy. For full details of assessment refer initial assessment form in
 medical record. Mr Davies describes his mood as ‘worried’ and ‘low’ and that he has been  
 having difficulties managing his health and medical conditions prior to admission. Justin
 states that his life has changed considerably in the last 4/52. He feels he has gained weight
 and lost all motivation to exercise.
 Current Occupational Performance Summary:
 – Justin currently a full  hoist transfer on ward due to NWB status in R) foot 2nd to wound
 – Set up assistance required with eating in bed using bed tray
 – Set up assistance with grooming in bed. Nursing staff placing all items within reach (bowl,
 hair brush, tooth brush, etc)
 –  Max assist with hoist transfer from bed to wheeled commode for bathing. Once setup,
 independent upper body (UB), Max A with lower body (LB). Significant SOB ++.
 – Currently only wearing hospital gown, Mod A x 1 to don it when lying in bed.
 Occupational Performance Plan
 – Due to Justin’s current weight of 160kg, Justin requires full hoist transfer on ward from
 bed to bariatric wheeled commode, HBC and MWC.  2 x staff to push in MWC. Awaiting permission
 – Awaiting go ahead from PT and medical team to trial Justin with a bariatric wheeled
 zimmer frame during transfers. Will complete joint assessment with PT once approved.
 – Requires medical follow up and plans
 – Will commence self care review 1/7
 ——————————————— H. Joans (Harriet Joans, Occupational Therapist) #4987—
20/05/present datePhysiotherapy: Initial mobility review with Mr Davies, admitted to ward with R) foot ulcer.
1300hrsCurrently NWB in R) foot. Dressing in situ.  Consent gained.
 Current transfers and mobility status on ward:
 T/F: full hoist (XL sling size) on ward from bed to HBC/Wheeled commode/MWC/Bed
 Mobility: MWC on ward only with 2 x staff pushing
 Bed mobility: Slide sheets x 2 for repositioning as appropriate otherwise full hoist
 Standing balance: Not assessed due to NWB status  
 Sitting balance: Nil issues noted SOEOB or in HBC or MWC
 Plan: full mobility and transfer review once medical permission to trial a bariatric wheeled
 zimmer frame granted. Will F/up 1/7 with medical team
 – Liaise with occupational therapy re: bariatric electric wheelchair to facilitate access to gym
 ————————————S Richards Sam Richard, PT #9898————————————
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