TASK 11: Name        :           Cheryl Cook                                                  D.O.B  :           2/11/1970

Admitted         :          7th August 2008 Discharged   :          9th August 2008 Diagnosis     :           Laryngities

Patient History: Accompanied by husband to hospital, suffering from hoarseness, sore throat, dry cough, voice loss, lasting 18 days, smoker (0.5 / day), alcohol intake – 30

History of upper-respiratory infections, hypothyroid since 2005-controlled with thyroxin.

No allergies but suffers mild asthma-well controlled, no major attacks for four years

Social History: Married to Christopher, two children aged 5 and 8: works as jazz singer and in loud busy bar, worried about possibility of not being able to keep singing, important concerts next month

Nursing Notes: Laryngoscopy – found vocal cord polyps/nodules; given lozenges (Strepsils-every 4 hours) Corticosteroids (Prednisone inhaler every 6 hours) given water hourly

Discharge Plan: Patient to see ENT specialist re polyps: if any pain or problems in future to see a doctor immediately told to avoid smoking alcohol/caffeine/decongestants until recovered, Continue prednisone for next 7 days strepsils as needed. Rest voice completely, avoid clearing throat, avoid whispering, avoid upper respiratory infections, recommendation to stop bar work-patient reluctant to do this, drink plenty of fluid, gargle salt water, hot steamy shower-install humidifier in home (use bowl of hot water for inhalations 5 mins 2 x daily)

Writing Task: Using the information in the case notes, write a letter of referral to Dr. Tim Richards, 28 Acacia Ave, Box Hill 3128

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