Case Study ‘Leonard’
Leonard is a 65-year-old man who was admitted to an acute medical ward via the Emergency Department after falling at the local shops. He did not sustain a fracture, although he had severe bruising of his face and hip. His main diagnosis was decompensated liver disease. His presenting symptoms included dyspnoea, anorexia, lethargy, jaundice and ascites. Leonard is being seen by a social worker as he was not coping at home prior to admission. He has also been referred to a dietitian. Leonard’s past medical history includes alcoholic liver disease caused by heavy alcohol intake (180 g/day for years, 40 g/day for last month). He recently claimed to have ceased drinking alcohol. Leonard has mental and behavioural disorders due to alcohol dependence, a decubitus ulcer on the shin of his left leg (0.5 cm long), arthritis in his lower back, anaemia, industrial deafness, mild hypotension, some evidence of urinary incontinence, lower limb oedema, and regular falls. Leonard lives with a housemate in his own house, although both men are independent of each other. The housemate has a mental illness and is rarely home, so is unable to provide support for Leonard. Leonard’s wife died of cancer 15 years ago at the age of 43. They have no children. Leonard cared for her at home for many months before she died. Leonard’s sister believes that he developed a fear of hospitals from that time, and began drinking heavily after his wife’s death. Leonard has two sisters, both older than him, who live nearby and are supportive, but cannot provide care at night. Both sisters have expressed their concern that Leonard will need community support to manage at home.
Six months ago Leonard was independent in all self-care, but his functioning has deteriorated over the last six months. His personal care has declined, and he has become quite unkempt over this time. The house and garden have also been neglected, and his sisters have been cleaning the house occasionally. Leonard appears quite confused and disorientated. He had a Mini Mental State Examination (MMSE) score of 28/30, but appears to have little insight into his problems and also exhibits motor planning difficulties. Leonard is keen to return home and cooperates with treatment interventions. He is, however, resistant to suggestions that he should have support services at home.
Leonard uses a walking frame for mobility. He is currently very slow and can be impulsive when mobilising. He requires the physical assistance of one person to negotiate steps with a rail in the hospital, needs supervision for transfers, and can participate in self-care activities when set up. Leonard has some difficulties planning tasks needed to get dressed. He lives in a single storey house, with four steps to the front and two steps at the back with no rails. There is one 300 mm internal step down to the toilet via a sliding door. There are no grab rails in the toilet. The bathroom is adjacent to the bedroom and consists of a separate bath and shower recess with a 100 mm shower hob and curtained access, but no rails. Leonard usually sits in a low recliner armchair and his bed is low and soft. He has an electric stove and microwave oven to prepare food.
Leonard used to work as a boilermaker in a very noisy factory prior to giving up work to care for his wife. Following her death, he worked casually doing a range of manual and labouring jobs, prior to his deterioration. Leonard used to be a keen gardener, and enjoyed fishing prior to his wife’s illness. Over the past six months Leonard has been spending more and more time in bed with no activities to interest him.
Residential care has been offered to Leonard, but he has declined, insisting that he wants to remain at home.
In your report you will address the following issues for Leonard based on this case study.
1. Identify, using the clinical reasoning cycle, Leonard’s falls and other health risk factors.
2. Critically evaluate three best-practice assessment tools appropriate for this case.
3. Critically apply a person-centred approach to support Leonard’s rights, while meeting your obligations as a health professional.