TASK 24 Today’s date: 05/04/12
You are Annie Smith, Cardiac Nurse, at the Prince Charles Hospital, Brisbane. Your patient is Mr. Yanlin Ma who underwent emergency cardio-thoracic surgery on the 31st March 2012.
Patient details DOB: 12th March 1980 Nationality: Chinese Marital Status: Single, no family in Australia
International student on scholarship for Masters in Information Technology
Medical & Surgical History No known allergies No previous surgery
Reports high blood pressure since late 2010 Medications: Panadeine Forte for headaches
Alcohol use: does not drink; Smokes 5-6 cigarettes per day; Weight 105kg, Height 182cm
Family history: Father died of aortic aneurysm at age 44
31/03/12: Presented to Royal Brisbane and Women’s Hospital with severe chest and back pain
CT scan showed severely dilated ascending aorta and type-A dissection; Transferred to Prince Charles Hospital
In acute pulmonary oedema on arrival; Echocardiogram performed, showing aortic valve incompetence
Open-chest surgery for repair of aortic aneurysm and aortic root replacement with mechanical valve
Post-operation: Hypertensive initially post-op, Blood pressure stablised by day 3
Satisfactory post-operative recovery, Reviewed by physiotherapist -exercise program provided
Started on Warfarin therapy, Cardiac outpatient’s appointment at 3 and 6 months post-op
To be discharged 09/04/12
Plan: Routine wound care, Patient education on Warfarin therapy,
Monitor BP. To be maintained at 120/80 or below
Social: Mother has come to Australia urgently from China. First time in Australia, no English
His lease on rental accommodation has recently expired. He will not complete this semester’s university assessment on time. His visa also expires at end of semester. Concerned about being able to lose weight and stop smoking
Writing Task: Write a referral letter to Ms Susan Williams, the hospital social worker, requesting her to see your patient before discharge to assist with: accommodation; letters for university and department of immigration; referral to programs for smoking cessation and weight loss/exercise.
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