Task

4 Case Notes: Sandra Peterson

Read the case notes below and complete the writing task which follows.

Time Allowed
Reading Time: 5 minutes
Writing Time: 40 minutes

Today’s Date
22/03/14

Hospital
Spirit Hospital - Medical Assessment Unit (MAU)
Admission Date: 20/03/2014
Discharge Date: 22/03/2014

Patient Details

• Name: Sandra Peterson

• DOB: 01/01/1923
• Address: 258 Addison St, Applethorpe
• Marital status: widowed – 25 yrs
• Next of kin: daughter – Ann Macarthur ph 0438856277

Diagnosis

• URTI (Upper Respiratory Tract Infection) – dehydration, bi- basal crackles

heard on chest, SOB
• Polypharmacy - on 24 medications at admission including a variety of OTC
medication encouraged by her daughter

History of Presenting Illness

• 13/03/2014 –coughing (yellow sputum)

• 18/03/2014 - ↓ed mobility, found in a sitting position on the floor in her
room, no injuries
• 19/03/2014 - ↑ed confusion had another fall in the toilet, no injuries
• 20/03/2014 - BP 190/90, SOB, dizziness, the 3rd fall, an ambulance was
called

Past Medical History

• Moderate dementia
• HTN
• Incontinent of urine – occasionally
Social History

• Lives in 2-bedroom flat with her daughter and son-in-law

• Daughter is overly supportive, overreacting and anxious about her mother’s
health
• Religion: Orthodox Christianity, attends church weekly with daughter
• Hobbies: listening to classical music, watching movies
• Requires some assistance with bathing, dressing and toileting
• Home Care worker visits 2 x wkly (bathing)

Medical Progress

• X- Ray – normal
• FBC – WCC 9.0, Hb 115g/L
• CT-brain – no acute changes
• Commenced on Augmentin 500 mg x BD, per os
• Now intermittent dry cough
• IV normal saline for 24 hrs
• Medications rationalised by doctor as detailed in discharge plan
• BP 150/70 - after adjustment of anti-hypertensives

Nursing management

• Vital signs: afebrile, haemodynamically stable, saturating 96% room air

• Mobility: short distance – independently ambulant with a seat walker, long
distance – wheelchair x 1 assistant
• Hygiene: full assistance require with bathing, some assistance with dressing
and grooming
• Psycho/Social: Mild confusion, but co-operative

Discharge Plan

• Community nurse referral

• Continue 500-mg tablet of Augmentin BD 5/7, should be taken at the start of
a meal
• Metoprolol 25 mg BD
• Candesartan 16 mg mane
• Medications – monitoring and assistance
• Daughter requires education/monitoring due to Hx of polypharmacy
• Ongoing care with personal hygiene required

 Writing Task

You are the charge nurse on the MAU where Mrs Sandra Peterson has resided
during her hospital stay. Using the information in the case notes, write a letter to the
Community Nurse at Spirit Community Health Centre, Cnr Bell & Burn Streets
Applethorpe, NSW, 2171. In your letter explain relevant background and medical
history and provide information about discharge requirements.

In your answer:

• Expand the relevant case notes into complete sentences

• Do not use note form
• The body of the letter should be approximately 180~200 words
• Use correct letter format

 Task 2 Case Notes: Robyn Harwood


Read the case notes below and complete the writing task which follows.

Time Allowed:
Reading Time: 5 minutes
Writing Time: 40 minutes

Today’s Date
12/07/12

You are Sonya Matthews, a registered nurse at the Spirit Hospital. Robyn Harwood
is a patient in your care. Read the case notes below and complete the writing task
which follows.

Patient Details

Name: Robyn Harwood
Address: 8 Peach St, New Farm
Phone: (07) 3397 2695
Date of Birth: 4 February 1951

Social Background

Marital status: Widow. No children. Lives alone
Next of kin: Megan Mack (Niece)
Niece lives with husband in Sydney who works as software engineer for Google
Australia. Sister died recently. No other relatives.

Medical History

Diabetes Mellitus Type 2
Metformin 500mg mane

Diagnosis

Right partial rotator cuff tear
Presented to Spirit hospital with pain and weakness in the right shoulder, especially
when lifting arm overhead.
Descending stairs at home and slipped, falling onto outstretched arm.
Xray and MRI showed a partial rotator cuff tear.
Orthopaedic surgeon discussed surgery. Patient prefers to try non-surgical
treatment.
Date of admission: 30-06-2012
Date of discharge: 12-07-2012

Treatment

Ibuprofen orally QID
Cortisone injections
Daily physiotherapy

Nursing Care Needs

Needs blood glucose level monitoring 4 hourly
May be elevated because of cortisone
Needs assistance with shower and housework
Orthopaedic review on 01/08/12


Writing Task


Using the information in the case notes, write a letter to the Nursing Director Ms.
Jenny Attard of the Blue Care Agency, requesting visits from the home care nurse.

In your answer:

• Expand the relevant case notes into complete sentences

• Do not use note form
• The body of the letter should be approximately 180~200 words
• Use correct letter format

 Case Notes: Betty Olsen

Read the case notes below and complete the writing task which follows.

Time Allowed
Reading Time: 5 minutes
Writing Time: 40 minutes

Today's Date
10/07/14

Notes

Betty Olsen is a resident at the Golden Pond Retirement Village. She needs urgent
admission to hospital. You are the night nurse looking after her.

Patient Details

Address: Golden Pond Retirement Village

83 Waterford Rd, Annerley, 4101

Phone: (07) 3441 3257

Date of Birth: 29/01/1931

Marital Status: Widowed

Country of birth: Australia

Social History

Moved to a retirement village following the death of husband in December 2012.

Next of kin: Son, Nicholas Olsen

53 Palmer Street, Warwick 4370
Ph (07) 4693 6552

Retired triple certificate nurse - was the matron of a small country hospital for 15
years. Very aware of and interest in health issues. Likes to discuss and be kept fully
informed of any changes to her medication or treatment.

Normally alert and orientated. Enjoys bridge, bingo and reading.

Medical History

Hypothyroidism since 2002

Hypertension since 2009
Glaucoma since 2010
Allergic to penicillin

Prescription Medications

Karvea 150mg 1 daily

Oroxine 0.1mg 1 daily am
Timoptol Eye Drops 0.5% 1drop each eye am & pm
Normison 10 mg as required

Non prescription Medication

Golden Glow Glucosamine Tablet - 1 with breakfast for arthritis

Vitamin C Complex Sustained Release – 1 with breakfast

Mobility / Aids

Independent with walking stick. Arthritis in hands. Wears glasses

Continence: Requires continence pad

Recent Nursing Notes

16/05/14
Flu vaccination

29/06/14
Complaining of indigestion following evening meal. Settled with Mylanta

07/07/14
Unable to sleep – aches in shoulder. Settled following 2 Panadol and 1 Normison

09/07/14
Requested Mylanta for indigestion,Panadol for shoulder pain – slept poorly

10/07/14 am
Tired and feeling generally weak. BP 180/95. Confined to bed. GP called and will
visit 11/7/14 after surgery.

10/07/14 pm
Didn’t eat evening meal. Says felt slightly nauseous. Trouble sleeping, complaining of
shoulder and neck pain. BP 175/95 Given 1 Normison 2 Panadol at 10pm
Rechecked 10.45pm – Distressed, pale and sweaty, complaining of persistent chest
pain,
BP 190/100. Ambulance called and patient transferred

Writing Task

Write a letter for the admitting doctor of the Spirit Hospital Emergency Department.
Give the recent history of events and also the patient’s past medical history and
condition.

In your answer:

• Expand the relevant case notes into complete sentences

• Do not use note form
• The body of the letter should be approximately 180~200 words
• Use correct letter format

 Assignment - Task 3 Case Notes: Ling Wu

Read the case notes below and complete the writing task which follows.

Time Allowed
Reading Time: 5 minutes
Writing Time: 40 minutes

Today’s Date
22/02/14

Patient details:

• Name: Ling Wu, female

• DOB: 01/03/1996
• Status: Single

Social History

• Ling is a student of the Bachelor of Accounting course in the University of

Western Sydney
• Enjoys cycling
• She lives in a 3-bedroom one-story house with her parents and younger
sister
• No tobacco, alcohol or drug use

Past Medical History: None

Allergies: no known allergies

Date of admission: 26/01/14 –Trauma Ward at St. Angus Public Hospital

Date of discharge: 23/02/14

Diagnoses

• Left tibial-fibular fracture secondary to cycle accident

• Left above-knee amputation
• Phantom limb pain

Description of accident: The patient was parked off the road, when a car skidded
across and collided with her cycle.

At Emergency Department
 • The initial assessment: an open tibial-fibular fracture of the left extremity
with near amputation
• Her Glasgow Coma Scale was 15 & head CT was negative
• Obs: BP- 178/90 mmHg, P-110bpm, RR- 22/min, SpO2 – 90 in room air
• The patient was taken to the operation theatre and above-knee amputation
was performed on the same day

Hospital progression

27/01/14

• Post – operative pain controlled with intravenous opioids (morphine) via

PCA infusion pump
• The limb has been elevated for one or two hours, two or three times each day
to reduce local oedema & pain
• She had been totally assisted with mobility
• Bladder care (Indwelling catheter inserted on 26/01/14 and removed on
28/01/14)
• Deep venous thrombosis (DVT) prophylaxis: The patient had negative
Dopplers and prophylaxed with Fragmin 5000 IU once daily, subcutaneously.
• Bowel management: The patient was started on Citrucel secondary to her
pain being treated with narcotics. On a high fibre diet and fluid intake
• Prevention of infection: Cephalexin IV tds - 5/7, protective dressing and
drainage.

01/02/14

• She complained of a cramping and twisted posture of the missing limb

(phantom limb pain), treated with opioids (Endone 5 mg BD), tricyclic
antidepressant (amitriptyline 10 mg tds)and antiepileptic (Neurontin 100
mg tds)

• Commenced participating in physiotherapy program and involved with pre-

prosthetic training.

15/02/14

• Orthopaedics
• Amputation incision remained intact,
• Stitches out
• Wound almost healed
• Residual limb wrapped with an ace bandage to ↓swelling and pain and re-
applied every 3-4 hours
• Mental state: insomnia, silent rumination, and social withdrawal
• She has a fear of being seen in public
• Consulted with a Social Worker
22/02/14

• Fragmin was discontinued. No signs of DVT were observed

• Phantom limb pain: she remained stable on Paracetamol-Osteo 665 mg qid
and Tramadol prn
• Min oedema of the stump w/peeling skin, no signs of infection
• Bowel management: Citrucel was discontinued. She started Coloxil with
Senna one tablet bd and Dulcolax suppository prn
• Fluids, Electrolytes, Nutrition: The patient was on a regular diet
• Able to walk with rolling walker for short distances along the ward and use
wheelchair for long distances, but needs ↑ assistance for stairs
• Trained to wrap the stump with ace bandage
• Parents were educated about assistance with ADL
• Vital signs with no abnormalities

Discharge plan:

• Warm compresses, ice packs and massage are recommended for phantom
limb pain
• To continue regular exercises as per physio program and dressings with ace
bandage to shape the amputated limb for fitting with a prosthesis
• The patient is at increased risk of developing post-traumatic stress disorder
(PTSD) or depression in the late period after the trauma. Peer counselling or
support groups to support her can be helpful
• The patient will be seen at the trauma clinic at 3:30 p.m. on 13/04/14

Medication at discharge (self-administration):

• Neurontin 100 mg q8 h
• Paracetamol Osteo 665 mg q8 h, prn
• trazodone 50 mg p.o. at bedtime prn
• Laxatives prn

Writing Task

You are a Charge Nurse at the trauma ward of St Agnus Hospital, Sydney. Using the
information in the case notes, write a letter to a Community Nurse at Spirit Family
Medical Practice, 12 Gar Street, Holy Hill, NSW, 2167. In your letter explain relevant
social and medical histories and request the Community Nurse to visit Ms Ling Wu
after discharge to provide proper health management and assistance for this patient
and her family.

In your answer:

• Expand the relevant case notes into complete sentences

• Do not use note form
 • The body of the letter should be approximately 180~200 words
• Use correct letter format