Anita Ramamurthy

!
CASE NOTES:
Mrs. Anita RamalTl.lrthy, a 59-year-old woman, is a patient in the (IPD) In-
patient-department of a hospital in which you are charge nurse.
Hospital: Sydney Women's Hospital
Patient details
Marital Status: Married
Height: 5' 4"
Weight: 87 kg
BMI: 33 -Obese
Address for #648, Bourke Street, Sydney

correspondence:
Admitted: 18/06/2017
Date of discharge: 23/06/2017
Diagnosis: Acute appendicitis with Appendicular llUJ1>
Treatment: Conservative management with IV antibiotics

(Planned for interval appendectomy in 6 wks)
Social Background: Businesswoman (Education Consultant) - Hectic

life, travel s a lot due to work
Lives with her husband, Mr. Krishnan
Ramamurthy
Two daughters both married.
Elder daughter stays in Sydney - about three hours
away, works as an Entrepreneur; ymmger daughter
in Canada, works as a dentist
Husband is the primary caregiver, elder daughter
visits with husband once an year, Scared of
hospitalization, prone to anxiety related to this
Fond of eating out, rarely cooks at home,
sedentary lifestyle, COl11)lains ofno time to
exercise due to work, does not drink or smoke
Diet: Whole Milk, Ice-cream shakes, Fruit drinks,

Doughnuts, Pancakes, Waffles, Pizzas,
Cheeseburgers, Biscuits, muffins, Cajun Fries,
Hash brown
Medical Background: Known case of Essential Hypertension (2014) and

Diabetes Mellitus type-2 (2010) (not co111>liant
with diabetic medication)
Admission Diagnosis: Col11)laints of pain in abdomen in right iliac fossa

since 17/06/2017 Pain was sudden in onset, acute
in nature and was non-radiating fever
( documented up to IO I -degree F), aversion to
food, evaluated outside where USG Abdomen
revealed Acute Appendic itis, admitted for further
evaluation and management
Physical Examination: Conscious, oriented, No pallor, no icterus, No
Clubbing, No Lymphadenopathy, no pedal oedema
BP: 126/84. Terq,-afebrile, Pulse- 72/min, RR-
22/min SP 02 98%, CNS-NAD, Chest- Bilateral
entry equal, No added sowxls
Nursing Management and Progress:
18/06/2017 - Abdom:n CT (plain) 18/06/2017 -acute appendicitis with

hypodense area in the region of base of appendix at its attachm:nt with
caecum? Phlegmonous collection. Possibility of sealed perforation cannot be
ruled out; total leucocyte count -21,000/currm
1/V Fluids, broad spectrum antibiotics (lmipenem), PPI, Analgesics,
antipyretics, other supportive treatment (6/6) , Regular Blood Sugar
Monitoring (6/6)
19/06/2017- TLC- 18,000/currm; corq,laints of considerable pain in abdomen,

headache, sips of water, extrem:ly di stressed, constipation, unable to pass gas
20/ 06/2017- TLC- 14,000/cumm; complaints of insomnia, headache,

tenderness in abdom:n, weakness, tolerating sips of coconut water and tea
21/06/2017-TLC- 11 ,000/cwnm; tolerating soft diet, can ambulate with

assistance, complained of weakness, Rev. Dietician re diabetic diet
22/06/2017- TLC - 8,000/cunm, able to ambulate slowly, independent with

AOL's
23/06/2017 Pt. stable, accepting orally well, adequate urine output, TLC
showing improving trend, Pt. stable, Rev. Endocrinologist - regular chart BSL,
INJ Human Mixtard Subcutaneously bd ( 12 hrly) 8 units ( I wk.) AC Breakfast
and 6 units AC dinner
Assessment: Pt. stable with plan for interval appendectomy (6

wks)
Medications: TAB Dolo(Paracetarrol) 650 mg, t.i.d. (8 hrly) for

3 days then PRN
TAB Pantocid(Pantoprazole) 40 mg mane for I 0
days
Tab Tenorid 25 mg (Atenolol) mane

Tab Supradyn(m.tltivitamin) mane, Tab Farobact
200 b.d.
Discharge Plan: Avoid strenuous activities/Travel

Advised to lose weight (exercise program to start
after appendectomy)
Normal Diabetic d iet and low-fat diet - Pt.
requests rrore information, esp. simple
recipes that can be easily prepared at hom:
Monitoring of fasting and postprandial blood
sugars (present chart during
Follow-up consultation)
Follow up in OPD on 30/06/2017 at 3PM.
Husband advised to contact us iIJI11ediately in
case of persistent high grade
Fever/pain (at 03492250);
Pt. concerned re rronitoring of blood glucose
levels and insulin injections
Husband requests home visit for demonstration
WRITING TASK 1
Using the information given in the case notes, write a referral letter to Ms.
Prabha, Shrishti Nursing Home Care Agency, Sydney, requesting a home visit
to provide instructions on self-monitoring of blood glucose levels and
administering insulin injections following Mrs. Rarnann.n-thy' s discharge.
In your answer
• Expand the relevant case notes into complete sentences
• Do not use note form
• Use letter format

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!

Hospital: Sydney Women's Hospital

Marital Status: Married

Height: 5' 4"

Address for #648, Bourke Street, Sydney

Date of discharge: 23/06/2017

Diagnosis: Acute appendicitis with Appendicular llUJ1>

Treatment: Conservative management with IV antibiotics

Social Background: Businesswoman (Education Consultant) - Hectic

Diet: Whole Milk, Ice-cream shakes, Fruit drinks,

Medical Background: Known case of Essential Hypertension (2014) and

Admission Diagnosis: Col11)laints of pain in abdomen in right iliac fossa

Nursing Management and Progress:

18/06/2017 - Abdom:n CT (plain) 18/06/2017 -acute appendicitis with

19/06/2017- TLC- 18,000/currm; corq,laints of considerable pain in abdomen,

20/ 06/2017- TLC- 14,000/cumm; complaints of insomnia, headache,

21/06/2017-TLC- 11 ,000/cwnm; tolerating soft diet, can ambulate with

22/06/2017- TLC - 8,000/cunm, able to ambulate slowly, independent with

Assessment: Pt. stable with plan for interval appendectomy (6

Medications: TAB Dolo(Paracetarrol) 650 mg, t.i.d. (8 hrly) for

Tab Tenorid 25 mg (Atenolol) mane

Discharge Plan: Avoid strenuous activities/Travel

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