TASK – 65
You are a nurse in Nurselead Outpatient clinic in Newtown hospital. You taking care of Mr. Pitman
Name of the patient: Mr Walter Pitman
Age: 69 years
Family: Married, has 2 children
Job: Retired accountant
Habits: No smoking or alcoholism Sedentary lifestyle, no exercise
Past history: Hypertension since 2008 Overweight
Admission date: 01.07.2018
Discharge date: 03.07.2018
PATIENT HISTORY
Present history: Accidental cut injury when using hand saw for cutting wood, referred by family physician for further care. Brought to Newtown hospital with deep lacerations on lower left arm. On admission wound cleaned, sutured and dressed well Prophylactic IV antibiotics starts and course completed
02.07.18 Stopped IV antibiotics. Oral antibiotics started, regular dressings Blood Pressure: 140/90 mmHg (sitting). 180/90 mmHg (supine)
03.07.18 Discharged, advised visits to Nurselead Outpatient clinic
04.07.18 Visited Nurselead Outpatient clinic of same hospital
He had severe pain with mild hematoma: recorded 8/10 on pain scale
Blood Pressure: 186/89 mmHg (sitting) 190/86 mmHg (supine)
06.07.2018 : Wound condition is better, healing, dressing done Blood Pressure: 190/86 mmHg (sitting)196/88 mmHg (supine)
08.07.2018 Wound is healing
Blood Pressure: 182/80 mmHg (sitting). 194/86 mmHg (supine)
11.07.2018 Wound dressing done, healing well without infection Blood pressure still elevated
14.07.2018: Wound healed well
Blood Pressure: 190/84 mmHg (sitting) 196/86 mmHg (supine)
Assessment: BP elevated?? Orthostatic hypertension Plan: Cardiac assessment for hypertension
Family physician referral
Writing Task: Write a referral letter to the family GP Dr Lacricell, Newtown 2137, asking him to do a full cardiac assessment and management of Mr Pitman’s hypertension.
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