Post Discharge Medical Review (ABI)

Medical Review Date: 1 November 2024 Method of Review: Telehealth Those Present: Patient, spouse, and Dr. Thomas Kelly. Current Medications: * Amlodipine 5mg daily * Simvastatin 20mg nocte * Sertraline 50mg daily Current Community/TI Rehabilitation Involvement: Attending outpatient physiotherapy twice weekly at City Hospital. Home or Community Support: Receives home help for personal care three times a week. Cognition (e.g., memory, insight, problem-solving, word-finding): Patient reports some ongoing memory difficulties, particularly with recent events. Insight into deficits is good. Word-finding difficulties are occasionally present. Physical Status (e.g., sensory, motor, olfactory, hearing, vision, speech, swallow, balance, orthopaedic, spasticity, wounds, bladder, bowel): Ambulates independently with a slight limp. Mild spasticity in the left lower limb. No issues with bladder or bowel function. Weight / Nutrition: Stable weight. Diet is generally good, but patient reports occasional poor appetite. Seizures: No seizure activity reported. Pain / Headaches / Sleep Management: Reports occasional headaches, managed with over-the-counter analgesia. Sleep is disturbed, waking frequently during the night. Depression / Anxiety / Mood / Behaviour: Mildly anxious, but mood is generally stable. No significant behavioural issues. Home Situation / Family or Whānau Concerns: Supportive spouse. Concerns about the patient's ability to manage independently in the future. Alcohol / Drug Use: No alcohol or drug use reported. Work, Learning or Training: Retired. Driving: Not currently driving. Medical Certificate: No medical certificate requested. Community Participation / Fatigue: Limited social participation due to fatigue. Reports feeling tired most of the time. Other: Patient is keen to explore options for improving sleep quality. Recommendations: 1. Rehabilitation Medicine Specialist to refer patient to a sleep clinic for assessment and management of sleep disturbance. 2. Rehabilitation Medicine Specialist to review medication list and consider adjustments to improve sleep quality.