Mr Lionel Ramamurthy, a 63-year-old, is a patient in the medical ward of which you are Charge Nurse.


Hospital: Newtown Public Hospital, 41 Main Street, Newtown
Patient details
Name: Lionel Ramamurthy (Mr)
Marital status: Widowed – spouse dec. 6 mths Residence: Community Retirement Home, Newtown Next of kin: Jake, engineer (37, married, 3 children <10)
Sean, teacher (30, married, working overseas, 1 infant)
Admission date: 04 February 2014
Discharge date: 11 February 2014
Diagnosis: Pneumonia


Past medical history: Osteoarthritis (mainly fngers) – Voltaren
Eyesight due to cataracts removed 16 mths ago – needs check-up


Social background: Retired school teacher (history, maths). Financially independent. Lonely since wife died. Weight loss – associated with poor diet.


Medical background: Admitted with pneumonia – acute shortness of breath (SOB), inspiratory and expiratory wheezing, persistent cough ( chest & abdominal pain), fever, rigors, sleeplessness, generalised ache.
On admission – mobilising with pick-up frame, assist with ADLs
(e.g., showering, dressing, etc.), very weak, ambulating only short distances with increasing shortness of breath on exertion (SOBOE).

Medical progress: Afebrile.
Infammatory markers back to normal. Slow but independent walk & shower/toilet. Dry cough, some chest & abdom. pain.
Weight gain post r/v by dietitian.
Nursing management: Encourage oral fuids, proper nutrition.
Ambulant as per physio r/v.
Encourage chest physio (deep breathing & coughing exercises). Sitting preferred to lying down to ensure postural drainage.
Assessment: Good progress overall
Discharge plan: Paracetamol if necessary for chest/abdom. pain.
Keep warm.
Good nutrition – fuids, eggs, fruit, veg (needs help monitoring diet).

Writing Task:

Using the information given in the case notes, write a discharge letter to Ms Georgine Ponsford, Resident Community Nurse at the Community Retirement Home, 103 Light Street, Newtown. This letter will accompany Mr Ramamurthy back to the retirement home upon his discharge tomorrow.
In your answer:
• Expand the relevant notes into complete sentences
• Do not use note form
• Use letter format

The body of the letter should be approximately 180-200 words.

Sample answer by Lifestyle Training Centre

Ms Georgine Ponsford,
Resident Community Nurse
Community Retirement Home,
103 Light Street, Newtown.

11/02/2014

Dear Ms Ponsford,


Re: Mr Lionel Ramamurthy, aged 63 years.

Mr Ramamurthy requires continuity of care and management, following his discharge today, after undergoing treatment for pneumonia. He was admitted with acute shortness of breath, wheezing, constant coughing, fever, rigors, sleeplessness and generalized ache.

Overall, Mr Ramamurthy has made good progress. He is no longer feverish, and his inflammatory markers are back to normal. He is able to carry out activities of daily living and can also slowly walk independently. However, he still suffers from dry cough as well as chest and abdomen pain. Paracetamol can be administered for the latter if required.

As per dietitian, Mr Ramamurthy has gained some weight, and he would require your help to monitor his diet. He needs to incorporate nutritious food such as eggs, fruits and vegetables in his diet and should intake more fluids.

In order to ensure postural drainage, as much as possible, it is better for him to sit than to lie down. Please encourage him to continue his chest physiotherapy: deep breathing and coughing exercises. He should be kept warm. Should you have further queries, please do not hesitate to contact me.


Yours sincerely,
Charge Nurse.
(Word count: 181)

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