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Document Created 06-Mar-2015, 12:00
Document Owner XYZ Hospital
Authored by XYZ Hospital on 02-Jan-2014, 19:00
Discharge summary
Encounter Type Medical consultation on hospital inpatient
Encounter Time 12-Feb-2015, 19:00 to 05-Mar-2015, 12:00
Encounter Disposition Discharge to relative's home
Care Setting Type Neurology department

Discharge details

Discharging consultant Mr Abacus
Date of discharge 05-Mar-2015
Discharge specialty Neurology
Discharge method Patient discharged on clinical advice
Discharge destination Daughter's residence

Admission details

Admission method Emergency
Date of admission 12-Feb-2015
Source of admission Usual place of residence

Clinical summary

Clinical Summary
Lady admitted with a dense right sided weakness, aphasia and dysphagia.
Patients swallowing remained unsafe and on the advice of SALT team non oral feeding initiated.
PEG successfully placed and feeding via this route started.
Daughter has been trained by dieticians and will continue the PEG feeding at home.
Pt has residual dense right weakness and will require ongoing rehab and physiotherapy.
Background of metastatic breast cancer and AF.

Diagnoses

Diagnosis CVA
Episode (first, new, other, ongoing) New
Date diagnosis made 14-Feb-2015
Date of first presentation 12-Feb-2015

Procedures

Procedure Percutaneous Endoscopic Gastrostomy (PEG) inserted 21/2/15

Assessment scales

Assessment scales NIHSS score 20

Participation in research

Participation in research None

Investigations and procedures requested

Investigations requested CT scan
Investigations results Established Left MCA Territory infarct.

Investigations requested ECG
Investigations results AF

Patient and carer concerns

Patient’s and carer’s concerns Nil from daughter.

Medications and medical devices

Medication Name Tamoxifen
Dose 10mg
Medication Frequency OD
Route oral
Medication Recommendations continue

Medication Name Aspirin
Dose 75mg
Medication Frequency OD
Route oral
Medication Recommendations continue

Allergies and adverse reactions

Causative agent No Known allergies
Description of the reaction No Known allergies

Safety alerts

None

Plan and requested actions

Actions
Patient has community DNAPR in place.
Agreed with patient or legitimate patient representative.
Daughter.
Patient requires ongoing physio and rehab.
Depending on progress will need input from social work regarding care arrangements.
dieticians will follow up patient regarding PEG feed and provide support as needed.

Information given

Information and advice given Explained to daughter diagnosis of significant stroke and that clinical prognosis uncertain.

Legal information

Advance decisions about treatment
Declined any further chemo-radiotherapy.
Patient previously stated did not want to be resuscitated – copy of community DNAR order with daughter.
Patient previously expressed wish to not have artificial feeding tubes.
Lasting or enduring power of attorney or similar
Daughter has power of attorney.

Social context

Household composition Lives on own.
Lives alone Yes.

Person completing record

Name Dr Reginald Namly
Designation or role Medical on call
Grade FY/SHO
Specialty Medicine
Document ID 265984E0-C97A-415F-ABF8-645645B96EA2 Version 1
Primary Recipient MGP Medical Centre
Copy Recipient Mrs A Smith - Community Nurse, OV9:Overtown Community Healthcare NHS Trust
 Phone 01136323244