TASK 15: Case Notes: Betty Olsen. Today’s date: 10/07/12.

Notes: Betty Olsen is a resident at the Golden Pond Retirement Village. She needs urgent admission to hospital. You are the night nurse looking after her.

Patient Details:

Address: Golden Pond Retirement Village 83 Waterford Rd, Annerley, 4101.      

Phone: (07) 3441 3257

Date of Birth: 29/01/1929 Marital Status: Widowed Country of birth: Australia 

Social History: Moved to a retirement village following the death of husband in December 2010.

Next of kin: Son, Nicholas Olsen, 53 Palmer Street, Warwick 4370. Ph (07) 4693 6552.

Retired triple certificate nurse – was the matron of a small country hospital for 15 years. Very aware of and interest in health issues. Likes to discuss and be kept fully informed of any changes to her medication or treatment.

Normally alert and orientated. Enjoys bridge, bingo and reading.

Medical History:       Hypothyroidism since 2000. Hypertension since 2007.

Glaucoma since 2007 Allergic to penicillin

Prescription Medications:    Karvea 150mg 1 daily Oroxine 0.1mg 1 daily am

Timoptol Eye Drops 0.5% 1drop each eye am & pm Normison 10 mg as required

Non prescription Medication: Golden Glow Glucosamine Tablet – 1 with breakfast for arthritis Vitamin C Complex Sustained Release – 1 with breakfast

Mobility / Aids: Independent with walking stick. Arthritis in hands. Wears glasses Continence: Requires continence pad

Recent Nursing Notes:

16/05/12: Flu vaccination

29/06/12: Complaining of indigestion following evening meal. Settled with Mylanta

07/07/12: Unable to sleep – aches in shoulder. Settled following 2 Panadol and 1 Normison

09/07/12: Requested Mylanta for indigestion,Panadol for shoulder pain – slept poorly

10/07/12 am: Tired and feeling generally weak. BP 180/95. Confined to bed. GP called and will visit 11/7/12 after surgery.

10/07/12 pm: Didn’t eat evening meal. Says felt slightly nauseous. Trouble sleeping, complaining of shoulder and neck pain. BP 175/95 Given 1 Normison 2 Panadol at 10pm

Rechecked 10.45pm – Distressed, pale and sweaty, complaining of persistent chest pain,

BP 190/100. Ambulance called and patient transferred

Writing Task: Write a letter for the admitting doctor of the Spirit Hospital Emergency Department. Give the recent history of events and also the patient’s past medical history and condition.

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