CASE 1 
INITIAL CONFERENCE
 Andy Davies

Present:   Nurse (case manager), Physical Therapy, and Occupational Therapy


Additional reports from: Physician, Speech Therapy  
Assessment:  Mr. Davies is a 78 yo male who has a history of Diabetes-type 2, osteoarthritis, CAD, HBP, as well as a history of recent falls    
Problem List:
  1. Needs assistance with medical management
  2. Poor fitting dentures making chewing difficult
  3. At risk for falls
  4. Poor endurance for ambulation and ADL
  5. Unsafe to drive
  6. Possible depression
  7. Social isolation
Goals:
  1. Independent in administering medication at prescribed times
  2. Independent in monitoring skin integrity
  3. Independent in monitoring blood sugar levels with FSBS Q unit
  4. Independent in meal preparation utilizing energy conservation techniques
  5. Be able to communicate by e-mail with a selected group of contacts with positioning to minimize stress on arthritic hands
  6. Independent in bathing in tub with adaptive equipment
  7. Decrease risk for falls as demonstrated by improvements on the Berg, Tinetti, and Get up and go tests
  8. Improve endurance so that patient can ambulate 40 feet before becoming SOB

Recommendations:

1.      Continue nursing intervention for instruction in medication and BS testing, monitor BP and skin integrity. (2-3x/wk-1week, 1-2x/week for 8 weeks)

2.      Continue Physical Therapy to improves function and decrease risk for falls (2x/week for 9 weeks)

3.      Continue Occupational Therapy to increase independence with ADL (2x/week for 9 weeks)

4.      Patient no longer drive due to poor depth perception, visual acuity and brake reaction time (report forwarded to Physician)

5.      Social work consult to assess depression and to assist with identifying and establishing community resources.

6.      Therapeutic Recreation consult to assist in established avenues for increased socialization and increasing his ability to participate in desired leisure activities as patient is not safe to drive.

7.      Obtain appointment with dentist to have denture evaluated

8.      Work with HHA to assure carry over of therapeutic interventions

2nd team meeting scheduled for 4 weeks- will have report from SW, TR and Dentist.

Developed and Maintained by Penny Bianconi
Last Updated May, 2003