Mary Trafford

Age: 80 years old female

Patient

Patient's Data

Patient’s name: Mary Trafford

Age: 80 years old female

Past Medical History

  • Hypertension
  • Hypercholesterolaemia
  • Asthma
  • Depression

Medication history/ Allergies

  • Amlodipine 10mg OD
  • Indapamide 2.5mg OD
  • Atorvastatin 20mg nocte
  • Omeprazole 20mg OD,
  • DuoResp Spiromax (MART) 1 puff BD
  • Sertraline 50mg OD
  • Amitriptyline 25mg nocte
  • Aspirin 75mg OD

Patient's Information

You are Sam. A district nurse and you are calling on Behalf of Mrs. Mary Trafford. You went to visit Mary to help with wound dressing. She mentioned to you that she had a fall yesterday when moving from her Room to her bathroom to use the loo. This is the 2nd fall in the last one month. She did not sustain any Injury. It was a mechanical fall; she says she tripped and fell. She lives alone in a 2-bed duplex (Town house).

Say NO to any other questions asked.

Patient says that her confidence has been affected and she lives in fear that she will fall again. She looks frail.

Patient will like to be left at home and would not consider going to a nursing home.

You have checked her lying and standing blood pressure – lying 118/75mmHg, standing 117/72mmHg. Patient was not dizzy on standing. Pulse is 68bpm full volume and regular, HS-s1, s2 nil murmurs. No obvious gait problems or neurology.

Idea: You are not sure what is causing her fall but you suspect it may be due to her being frail.

Concern- You are concerned that she lives alone and have had 2 falls in last 1 month.

Expectation– You want the GP to suggest measures to help prevent patient from falling.

Questions for the doctor

What can you do now to prevent patient from falling again?