TASK 52 You are the Registrar of the medical ward, Royal Adelaide Hospital. You are planning to discharge the following patient & to arrange follow-up visits with his GP at the place where the patient is living.
Patient’s Name : Mr. Luis Morgan Date of Birth : 7th August, 1955
Social History:Indigenous clerk, ex-smoker until last year,until then smoked 10-15 cigarettes daily for 35 years
Past Medical History : Anterior myocardial infarction 2 years ago, coronary
angiogram inoperable coronary artery disease, Hypertension, Type 2 diabetes mellitus for 10 years.
Current Medication : Glibenclamide 10 mg, Metformin 500 mg, but not compliant, reluctant to commence Insulin, Frusemide 40 mg, Aspirin 75 mg.
2 Jan, 2010 7:00 AM Subjective : brought into emergency department by ambulance at 7 inthe morning, acutely breathless, looks extremely unwell, unable to speak, sitting up gasping for breath
Objective: mildly obese, cold, sweaty, cyanosis, pulse – weal, rapid & irregular, BP- 160/100 mm Hg, Jugular venous pressure- elevated to jaw, heart sounds- inaudible, Inspiratory crepitations, mild pitting ankle oedema.
Assessment: Congestive heart failure probably due to recurrent infraction.
Plan: immediate treatment (oxygen, 100 mg IV frusemide, 5mg IV morphine, glyceryl trinitrate 600 micrograms), urgent investigations (complete blood picture, electrolytes and cardiac enzymes) ECG, CXR insert urinary catheter.
2 Jan, 2010 7:30 AM: Subjective : still acutely short of breath, all other symptoms – remain
Objective : elevated glucose (18.3 mmol/L), elevated serum creatinine (0.19 mmol/L) ECG consistent with acute inferior infarction with atrial fibrillation, CXR – obvious cardiomegaly & pulmonary oedema
Assessment : heart failure secondary to recurrent myocardial infarction
Plan: start IV isosorbide dintrate, oral digoxin, IV heparin, monitor intensively. Transfer to coronary care unit
3 Jan, 2010: Subjective : improved considerably, now able to talk, admits unwell for 2 days, mild chest discomfort on the day before admission, was planning to see community doctor but became acutely short of breath, called ambulance.
Objective : blood sugar level-well controlled all the signs significantly improved
Plan :stop nitrate infusion, continue other medication, Echocardiogram
14 Jan, 2010: Subjective : has made gradual recovery, now ready to be discharged, can walk along the corridor for 15 minutes without breathlessness.
Objective : heart – lungs – kidney’s functions – stable, Echocardiogram – moderately dilated left ventricle with mild mitral regurgitation, functional impairment – moderate.
Plan : Change the current medication into oral forms (frusemide, aspirin, digoxin, warfarin, twice daily insulin), refer to his GP for regular follow-up visits and dosage adjustment.
Writing Task: Using the information in the case notes, write a letter of referral to Dr. Susan Wang, General Practitioner at the Family Care Clinic, 1009 Melbourne Street, North Adelaide, Sa 5006.
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