TASK – 66 Mrs Aisha Amari is a 75-year-old woman presenting in the clinic in which you work.

Clinic: Westborough Medical Clinic, Westborough 2065

Patient details           

Name: Aisha Amari   

Age:    75       

Residence:      Braybrook

Admission date:         16^th of July, 2017                               

Discharge date:          16^th of July, 2017

Presenting complaint:Left foot turns out on ambulation. Weak ankle  Ankle pain: chronic – burning sensation

Past medical history:             Mild memory loss       Vision blurry – retinal damage Hypertension – 3 years

Type 2 diabetes – 18 months

Past surgical history:            Cataract surgery (1992)          Appendectomy (circa 1986)

Family history:          Unknown

Diet:                Diabetic                      Low cholesterol          Family brings some meals

Medications:  Self-administered (son calls to remind):         Paracetamol as required Deep heat cream Diabex

Beta blockers                          Calcium channel blockers

Physical review:        5’8″ 63kgs                    Alert and oriented

Hearing and speech are within normal limits Skin intact                   Continent of bowel and bladder

Assessment:   Ambulates / transfers independently No assistive devices in house               No recent falls

Mobile phone with her at all times Pull-cord in bedroom and bathroom

Notes: Speaks only Arabic.

Son (Ahmed) interpreter and information source He is very involved – shopping, errands, finance

Management plan:    Check foot / ankle.

Personal assistance required shower 2d/4h/wk Needs help with dressing

Some household chores and laundry Needs installation of assistive devices

WRITING TASK: Using the information given in the case notes, write a referral letter to home care nurse, Sharon Wilkins, at “Prestige Care”, 393 Victoria Road, Newtown, Braybrook, who will be attending to Mrs Amari at home.

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