Last updated:
26 March 2019 Version 006
Full Name: Laura Hales PIP11335582/102
ID:
Job Center Plus Letter 20/2/2019
Passport 509904655
Time Started: 10:35
Time ended:
Individual that attended
Not Applicable
FME xxxDo Previous PA4 1stxxx
Hernani Cudal
Disability Assessor/ Physiotherapist
Not Applicable
FME HOC Medication SOH IO MSE MSK Vision Act1 Act2 Act3 Act4 Act5 Act6 Act7 Act8 Act9
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CQ 3/12/2018
Consultant Rheumatologist letter 7/10/2018 stating psoriasis, long standing thoracic pain and childhood Pneumonia
Discharge letter 16/6/2011 due to scarred abdominal skin
Gastroenterologist letter dated 27/9/2017
Handwritten information not dated
Photo copy of box of medication
Discharge letter regarding left hip injection 24/7/2017
Communication logs report with multiple dates
Page 2 of PA1 17/1/2019
Another copy of communication logs report first date is 17/1/2019
Very poor copy of sick note, unreadable
GP history of condition not dated
GP letter 21/2/2019
No further evidence available at the time of the assessment
Abbreviations which may be included in the report are History of Conditions (HOC) Further Medical Evidence (FME),
Social and Occupational History (SOH), Functional History (FH), Informal Observations (IO's), Muscular Skeletal
Examination (MSK), Mental State Examination (MSE), Current Medical Treatment (CMT),Occupational Therapy (OT),
VE (Visual Examination), PIP (Personal Independence Payment), CQ (Claimant Questionnaire), CSE (Cognitive State
Examination)
HOC xxxDo Previous PA4 1stxxx
PRIMARY CONDITION-
Osteoarthritis of the left hip (2016) and shoulder (November 2018), T7-T8 disc bulge (2014) related to Sheuermann’s
Disease (1997)
Diagnosed by specialist.
Joints affected:
Reported symptoms: pain in left hip all day every day, pain in left shoulder all day everyday, pain in her
thoracic spine all day everyday.
Sees GP 20 times a year on average and that includes consultation for other conditions.
Sees specialist 2 times a year on average (hip and shoulder).
Has not seen specialist for her thoracic spine since 2014.
Has been prescribed medication and reports that it is partially effective.
Has not been admitted due to the above condition in the last 12 months.
Fluctuation and severity of symptoms worsen in the last 12 months.
Awaiting appointment for Physiotherapist for her hip and shoulder.
SECONDARY CONDITION-
Endometriosis 10/102016
Diagnosed by specialist.
Reported symptoms: abdominal pain all day every day.
Experiences symptoms (how many times a day/week/months and for how long does symptoms last)
Sees GP 20 times a year on average and that includes consultation for other conditions.
Sees specialist twice a year on average.
Has been taken off hormonal therapy medication recently.
Has not been admitted due to the above condition in the last 12 months.
Fluctuation and severity of symptoms worsen in the last 12 months.
Possible surgery in the future and still waiting for someone who will do the surgery.
OTHER CONDITIONS-
Psoriasis (1994).
Diagnosed by specialist.
Reported symptoms: red skin all over all day every day.
Sees GP 20 times a year on average and that includes consultation for other conditions.
Now under the care of the GP.
Has been prescribed medication and reports that it is partially effective.
Has not been admitted due to the above condition in the last 12 months.
Fluctuation and severity of symptoms remained the same in the last 12 months.
There is no new planned treatment in the next 12 months.
Dyslexia (1993)
Diagnosed in school.
Reported symptoms: she uses special apps to read, she will scan it and it will be read to her. Does not use
colour overlay.
Sees GP 20 times a year on average and that includes consultation for other conditions.
Does not see specialist.
Has not been prescribed medication.
Has not been admitted due to the above condition in the last 12 months.
Fluctuation and severity of symptoms remained the same in the last 12 months.
There is no new planned treatment in the next 12 months.
IBS – Irritable bowel symdrome (2017)
Diagnosed by specialist.
Reported symptoms: abdominal pain all day every day. Experiences diarrhoea and constipation 50% of the
time each.
Sees GP 20 times a year on average and that includes consultation for other conditions.
Now under the care of the GP.
Has been prescribed medication and reports that it is partially effective.
Has not been admitted due to the above condition in the last 12 months.
Fluctuation and severity of symptoms remained the same in the last 12 months.
There is no new planned treatment in the next 12 months.
Learning difficulties.
Diagnosed in school.
She said she can write and read all day every day. Has not been prescribed colour overlay.
His partner found her an app so she can scan it and it is read to her.
She said at work it is more verbal instruction and only able to read simple text but not complex specification.
She said she has special Educationa Needs Report previously.
Seh does nto have documents stating she has learning difficulty.
Has not been prescribed medication and reports that it is partially effective.
Has not been admitted due to the above condition in the last 12 months.
Fluctuation and severity of symptoms remained the same in the last 12 months.
There is no new planned treatment in the next 12 months.
She has provided the above information during the assessment. It is an accurate reflection of the current situation.
There are no other reported conditions which affect function.
Medication
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Tramadol 60mgs 4 times daily for over all pain
Diclofenac 50 mg 1 three times daily for over all pain
Paracetamol 500mg 6 tablets a day for over all pain
Senakot 2 at night for IBS
No over the counter drugs
States compliance is good. No side effects unless otherwise indicated.
SOH
Lives in a 2-bedroom ground floor flat.
Able to access all areas of the flat.
Stairs: no stairs.
Aids/ adaptations: no aids and adaptation but she said she has a walk-in shower that they build themselves in
addition to her bath.
The bathroom and the toilet are situated in the same level.
Never had full driving license.
Use to work as shoe maker for NHS (35.5 hours a week). She has done it for 6 years. She stopped working in 2014
and she said she cannot do it anymore because of her condition.
She said she and her partner only do online shopping. She said the last time she physically shopped was 18 months
ago approximately.
She said that in general she can walk 2 minutes without aid before she has to stop and will need 20 seconds rest
before she can cover the same distance again as needed or as required. She said she is limited by pain. She said she
is 50% slower than normal approximately.
She said in general she goes out once a week to do small shopping however she said that she only stays in the car
while partner buys the items needed.
Reported hobbies: listening to books.
Has one dog. Partner walks the dog.
CQ completed by herself and she said it is her handwriting. She said she scan it then it will be read to her then she
will speak to the app then it will write it for her then she will copy.
No other relevant functional history.
Informal Observation (IO)
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Mobility: Mobilize at normal pace and normal gait pattern unaided without obvious pain or difficulty. Commented [HC1]: No restriction.
Mobilise at normal pace and normal gait pattern unaided without
obvious pain or difficulty.
Grip and upper limb: Seen to move both hands in normal coordinated way.
Sat and stood with ease not needing support.
Attended the assessment alone and was able to answer all questions with intelligence.
Engaged appropriately during assessment.
Was dressed appropriately for the weather and the assessment.
Communicated well with assessor and able to express self well.
Coped well at the assessment and had good concentration.
Showed good eye contact, able to establish rapport during the assessment and able to hold a meaningful
conversation with the assessor.
Was able to maintain the same level of energy throughout the assessment.
Average body build.
No shortness of breath and fatigue noted throughout the assessment. Commented [HC2]: Typical No restriction
Engaged appropriately during assessment.
Was dressed appropriately for the weather and the assessment.
Appearance: Dressed appropriately for time and place. Appeared well kept and well nourished. Communicated well with assessor and able to express self well.
Behaviour: no signs of anxiety and agitation. Alert, coherent and cooperative. Coped well at the assessment and had good concentration.
Mood: good eye contact, open body language, no signs of low mood. xShowed good eye contact, able to establish rapport during the
Cognition: understood and was able to follow the process of the assessment. Understood the purpose of assessment and able to hold a meaningful conversation with the
assessment. Understood questions asked and was able to answer with intelligence and promptly. Able to answer assessor.
Was able to maintain the same level of energy throughout the
hypothetical question in the assessment with intelligence and insight. assessment.
Intellect: understood questions asked and gave appropriate answers to all questions. Average body build.
Thought disorder: no evidence of thought disorder. Able to follow process of assessment well and did not looked No shortness of breath and fatigue noted throughout the
distracted. No odd behaviour noticed during assessment. assessment.
Insight: had good insight to both condition and medications. Acknowledges diagnosis and able to discuss
symptoms accurately and knows the significance of treatment.
Memory: able to recall both past and present events . Commented [HC3]: Appearance: Dressed appropriately for
time and place. Appeared well kept and well nourished.
Speech: Normal in flow, rate and tone. Content of speech is appropriate and makes sense. Behaviour: no signs of anxiety and agitation. Alert, coherent
and cooperative.
Mood: good eye contact, open body language, no signs of low
mood.
Cognition: understood and was able to follow the process of
MSE: the assessment. Understood the purpose of assessment.
Understood questions asked and was able to answer with
intelligence and promptly. Able to answer hypothetical
Good MSE question in the assessment with intelligence and insight.
Intellect: understood questions asked and gave appropriate
answers to all questions.
Thought disorder: no evidence of thought disorder. Able to
follow process of assessment well and did not looked
distracted. No odd behaviour noticed during assessment.
MSK: Speech: Normal in flow, rate and tone. Content of speech is
FME HOC Medication SOH IO MSE MSK Vision Act1 Act2 Act3 Act4 Act5 Act6 Act7 Act8 Act9 appropriate and makes sense.
Self harm and suicide:
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Spine:
Chin to chest: Able to bring chin to chest without obvious difficulty Commented [HC4]: Able to bring chin to chest and reports
pain at end of range. Grimace observed.
Cross arm and turn trunk to right: able to cross arms across chest to reach opposite shoulder and turn trunk to the
right without obvious difficulty Commented [HC5]: able to cross arm across chest to reach
opposite with the XXX and only able to reach mid arm shoulder
with xxx and turn trunk to the right and report pain at end of
Cross arm and turn trunk to left: able to cross arms across chest to reach opposite shoulder and turn trunk to the range. Grimace observed.
left without obvious difficulty
Commented [HC6]: Cross arm and turn trunk to right: able to
Bend forward in sitting to touch toes: able to touch toes in sitting position without obvious difficulty cross arms across chest to reach opposite shoulder without
obvious difficulty and turn trunk to the right and reports pain at
end of range.
Bend forward in standing: able to bend lower back and reach knees when standing without support and without
Cross arm and turn trunk to left: able to cross arms across chest
obvious difficulty
to reach opposite shoulder without obvious difficulty and turn
trunk to the right and reports pain at end of range.
Lower Body
Stand on tip toes:able to stand on tip toes without support and without obvious difficulty
Bend both knees to squat:able to bend both knees to squat down without support and without obvious difficulty
Stand on right leg: able to stand on right leg whilst lifting opposite foot off the ground without support and
without obvious difficulty
Stand on left leg: able to stand on left leg whilst lifting opposite foot off the ground without support and without
obvious difficulty
Upper body:
Put hands behind the head: able to put right hand behind head but only able to move shoulder 45 degrees to the
side. Grimace observed.
Put hands behind back: Able to put right hand behind middle of the back but only able to put left hand at the
back side of the hip. Grimace observed. Commented [sL7]: Sir bakit po right shoulder restriction?
Power Grip: Able to maintain strong power grip with right and left hand.
Pincer Grip: Able to maintain strong pincer grip with right and left hand.
FME HOC Medication SOH IO MSE MSK Vision Act1 Act2 Act3 Act4 Act5 Act6 Act7 Act8 Act9
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VISION: no visual restriction reported. uses prescription glasses to see.
Choose an item. to complete the distance vision test. Distance vision testing showed visual acuity of Choose an item.
Choose an item. to complete the near vision test. The test result was assessed as Choose an item.
GENERAL JUSTIFICATION
1. Preparing food*
Choose an item.
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CQ states need help
FH: states unable to prepare a simple meal. Reports restricted by her left shoulder issue and that includes.
IO and MSE states good cognition, intellect, insight, concentration and memory.
IO and MSE states no signs of anxiety and low mood. Not on significant mental health medication.
IO and MSK states good grip of both hands.
IO and MSK states good lower limb function and able to do standing MSK without support.
On pain medication.
A: Therefore with all the available evidence it is likely that she is able to prepare and cook a simple meal safely to a
timely acceptable standard and repeated for majority of days unaided.
2. Taking nutrition
Choose an item.
CQ states no restriction
FH: states eats daily and uses normal cutlery. Reports no other issues.
IO and MSE states good cognition.
IO and MSE states no signs of anxiety and low mood. Not on significant mental health medication.
IO and MSK states good grip of both hands.
On pain medication.
IO states average body build. No dietician input and no supplement.
A. Therefore with all the available evidence it is likely that she is able to take nutrition safely to a timely acceptable
standard and repeated for majority of days unaided.
3. Managing therapy or monitoring a health condition
Choose an item.
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CQ states need help
FH: States in general she is compliant with medication and takes it independently and they come in original
packaging but sometimes she forgets if she has taken them or not.
IO and MSE states good cognition, intellect, insight, concentration and memory.
IO and MSE states no signs of anxiety and low mood. Not on significant mental health medication.
IO and MSK states good grip of both hands.
IO and MSK states good left shoulder function and restricted right shoulder.
IO and MSK states good lower limb function and able to do standing MSK without support.
On pain medication.
A: Therefore with all the available evidence it is likely that she is able to manage medication or monitor health
conditions safely to a timely acceptable standard and repeated for majority of days unaided.
4. Washing and bathing
Choose an item.
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CQ states need help sometimes
FH: Able to shower independently daily. She use the shower because of her hip and shoulder pain.
IO and MSE states good cognition.
IO and MSE states no signs of anxiety and low mood. Not on significant mental health medication.
IO and MSK states good grip of both hands.
IO and MSK states good left shoulder function and restricted right shoulder.
IO and MSK states good lower limb function and able to do standing MSK without support.
On pain medication.
A. Therefore with all the available evidence it is likely that she is able to manage washing and bathing safely to a
timely acceptable standard and repeated for majority of days unaided.
5. Managing toilet needs and incontinence
Choose an item.
CQ states need aid sometimes
FH: states can get on and off the toilet independently .States able to manage toilet hygiene independently
IO and MSE states good cognition.
IO and MSE states no signs of anxiety and low mood. Not on significant mental health medication.
IO and MSK states good grip of both hands.
IO and MSK states good left shoulder function and restricted right shoulder.
IO and MSK states good lower limb function and able to do standing MSK without support.
On pain medication.
A. Therefore with all the available evidence it is likely that she can manage toilet needs and incontinence safely to a
timely acceptable standard and repeated for majority of days unaided.
6. Dressing and Undressing
Choose an item.
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CQ states need help sometimes
FH: Able to dress and undress independently but needs help sometimes with her bra due to her left shoulder
restriction.
IO and MSE states good cognition, intellect, insight, concentration and memory.
IO and MSE states no signs of anxiety and low mood. Not on significant mental health medication.
IO and MSK states good grip of both hands.
IO and MSK states good left shoulder function and restricted right shoulder.
IO and MSK states good lower limb function and able to do standing MSK without support.
On pain medication.
.
B. Therefore with all the available evidence it is likely that she is able to manage dressing and undressing safely to a
timely acceptable standard and repeated for majority of days with aid.
7. Communicating Verbally
Choose an item.
CQ states need aid
FH: states able to understand spoken language and able to express self. Reports no other issues. Does not use
hearing aid.
IO and MSE states good cognition, intellect, insight, concentration and memory.
MSE and IO states able to communicate well with the assessor and able to establish rapport
A. Therefore with all the available evidence it is likely that she is able to communicate verbally in a timely acceptable
standard and repeated for majority of days unaided.
8. Reading and understanding signs, symbols and words
Choose an item.
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CQ states need aid sometimes
FH: states she will not be able to read appointment letter and will have to scan it in her app so that it will be read to
her. She has never used colour over lay. She said her work for the NHS is manual labour. Has not completed GCSE.
Went to main stream school. Did not go to college. She was put on certain jobs that did not require reading. She
said she can read signs like danger or do not enter. She said she will be able to read simple invitation letter. Will not
be able to read and understand demand letters but will be able to understand it using her reading app.
IO and MSE states good cognition, intellect, insight concentration and memory.
No visual restriction reported.
ASK QLS
A. Therefore with all the available evidence it is likely that she can reliably read and understand information to an
acceptable standard for majority of days unaided.
9. Engaging with other people face to face
Choose an item.
CQ states does not go out often
FH: states can engage with assessor alone even if it is in the clinic but not as comfortable. Reported no anxiety
issues when engaging with people one to one in general but she does not like socialising.
IO and MSE states good cognition, intellect, insight, concentration and memory.
MSE and IO states has good eye contact, open body language and no signs of anxiety and low mood.
Not on significant mental health medication.
A. Therefore with all the available evidence it is likely that she is able to engage with others face to face in a timely
acceptable standard and repeated for majority of days unaided.
10. Making budgeting decisions
Choose an item.
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CQ states need help
FH: states does not have the cognitive ability to make budgeting decision. States that partner manages the finance.
IO and MSE states good cognition, intellect, insight, concentration and memory.
IO and MSE states no signs of anxiety and low mood. Not on significant mental health medication.
A. Therefore with all the available evidence it is likely that she is able to make budgeting decisions to a timely
acceptable standard and repeated for majority of days unaided.
11. Planning and following journeys
Choose an item.
CQ states need help
FH: states that even has no physical restriction still unable to plan and follow a journey. Reports restricted by
poor cognition.
IO and MSE states good cognition, intellect, insight, concentration and memory.
IO and MSE states no signs of anxiety and low mood. Not on significant mental health medication.
SOH states she Never had full driving license.
SO states she and her partner only doe online shopping.
So states she goes out once a week to do small shopping however she said that she only stays in the car while
partner buys the items needed.
There is no evidence of overwhelming psychological distress.
A. Therefore with all the available evidence it is likely that she is able to plan and follow a journey timely to an
acceptable standard and repeated for majority of days unaided.
12. Moving around
Choose an item.
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CQ states mobilise less than 20 meters without aid. Commented [HC8]: In the last xxx months she said that in
FH: She said that in general she can walk 2 minutes without aid before she has to stop and will need 20 seconds general she can walk xx meters/minutes with xxxx before she has
to stop and will need xxx minutes rest before she can cover the
rest before she can cover the same distance again as needed or as required. She said she is limited by pain. She said same distance again as needed. She said she is limited by pain and
she is 50% slower than normal approximately. fatigue. She said she is xxxmore than 100% slower than normal
approximately.
SOH states she does not have physical restriction and has no problem with her mobility.
IO states good lower limb function.
She reported no physical restriction.
IO states she mobilize at normal pace and normal gait pattern unaided without obvious pain or difficulty.
A. Therefore with all the available evidence it is likely that she is able to move around more than 200 meters safely
to a timely acceptable standard and repeated for majority of days xxeither aided or unaided.
Time Started:
Time ended:
SUMMARY AND DECLARATION
Years: Month:
[]No review recommended
1. Previous PA4 (H and M) If there is previous PA4 in FME please do the following:
a. Sample: PA4 10/2/2016 (1b, 2a, 3a, 4b, 5b, 6b, 7a, 8a, 9a, 10a, 1a, 12e)
b. Can you put in activity 1-12 the following; you need to break them down.
c. See sample: Previous PA4 states 1b.
2. Delete letters (H)
3. Check PIP# and name
