Name : Joel Silbersher Age 12
Admitted : 10 September 2008
Discharged : 13 September 2008
Reason for admission: Dehydration, weak rapid pulse, orthostatic hypotension, acetone breath, tachycardia, weakness, fatigue, N & V. abdominal cramps
Diagnosis: Diabetic ketoacidosis
History: IDDM Type 1; Joel was staying with his friends in Ballarat for the weekend; Insulin injections (Self-administered) neglected, increased sweet and fatty food intake; Stress levels were high; embarrassed by condition.
Nursing Notes: IV fluids, IV insulin administration, blood glucose monitoring; electrolyte replacement; K+ replacement. Pt. condition improved gradually with above, maintained consciousness; glucose added to IV when blood glucose normalized.Pt. commenced on low-fat, low-sugar diet

Discharge Plan: Pt. and family educated re prevention of future episodes, carry medical ID (indicating diabetic, name of GP, type and dose of insulin) at all times, tell friends and family how to respond in case of hypoglycemia; need for complying with dose and self- medication emphasized; diet plans given, exercise options outlined.

Writing Task: Using the information in the case notes, write a letter of referral to historical GP, Dr. Harry Coleman, St. Kilda Health Clinic, 35 Carlisle St, St Kilda 3182. DO NOT use note form in the letter. Expand the relevant case notes into full sentences. The letter should be approximately 200 words long.

Sample letter by Lifestyle Training Centre

Dr Harry Coleman,
St Kilda Health Clinic,
35 Carlisle St, St Kilda 3182.

13 September 2008

Dear Dr Coleman,
Re: Joel Silbersher, aged 12 years.

I am writing to refer Joel, who requires education on prevention of Diabetic ketoacidosis, following his discharge today as he is recuperating from an episode.

Joel, diagnosed with type 1 Insulin-Dependent Diabetes Mellitus, experienced a distressing incident over the weekend at a friend’s place. He consumed high-sugar and fatty foods, neglecting to self-administer his insulin injection. Consequently, Joel was admitted to the hospital, presenting symptoms such as dehydration, a weak rapid pulse, orthostatic hypotension, acetone breath, tachycardia, weakness, fatigue, nausea and vomiting, and abdominal cramps. The diagnosis confirmed Diabetic Ketoacidosis.

During hospitalisation, Joel received IV fluids and IV insulin. Continuous monitoring of his blood glucose levels was conducted, and electrolytes as well as potassium were replenished. To normalise his blood glucose levels, IV glucose was administered.

Joel is presently conscious and recuperating effectively; however, he is coping with stress and embarrassment following the recent episode. He was initiated on a low-fat and low-sugar diet.

In light of the above, it’s crucial to educate Joel and his family on preventing future episodes and ensuring prompt assistance in case of hypoglycaemia. Joel is advised to consistently carry a medical ID containing details about his condition, insulin dosage, and his GP’s name. Strict adherence to self-medication, dietary plans, and exercise is essential for effective management of his condition. If there are any further questions or concerns, please feel free to reach out to me.

Yours sincerely,
Registered Nurse.

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