TASK 38                    Today’s Date: 22/02/2012

Patient Details          

Name   : Ling Wu, female

Date of Birth         : 01/03/1994

Marital Status    : Single.

Social History : Ling is a student of the Bachelor of Accounting course in the University of Western Sydney.

She is a cyclist for many years. She lives in a 3-bedroom one-story house with her parents and younger sister.

No tobacco, alcohol or drugs

Past Medical History : None                                                            

Allergies         : No known allergies.

Date of admission      : 26/01/2012 trauma ward at St. Angus public hospital

Date of discharge    : 23/02/2012

Diagnosis                    Left tibial-fibular fracture secondary to cycle accident.

Left above- knee amputation              Phantom limb pain.

Description of accident         : The patient was parked off the road, when a car skidded across and collide with her cycle.

At Emergency Department

The initial assessment: an open tibial-fibular fracture of the left extremity with near amputation.

Her Glasgow coma scale was 15 and head CT was negative.

Obs: BP 178/90 mmHg. P-110 bpm, RR-22/min, SpO2-90 in room air.

The patient was taken to the operation theatre and above-knee amputation was performed on the same day.

Hospital progression 27/01/2012

Post-operative pain controlled with intravenous opioids (morphine) via PCA infusion pump

The limp has been elevated for one or two hours, two or three times each day to reduce local oedema & pain.

She had been totally assisted with mobility

Bladder care (Indwelling catheter inserted on 26/1/2012 and removed on 28/01/2012)

Deep venous thrombosis (DVT) prophylaxis: The patient had negative Dopplers and prophylaxed with Fragmin 5000 IU once daily, subcutaneously.

Bowel management: The patient was started on Citrucel secondary to her pain being treated with narcotics. On a high fibre diet and fluid intake.

Prevention of Infection: Cephalexin IV tds-5 days, protective dressing and drainage

01/02/2012 She complained of a cramping and twisted posture of the missing limb (phantom limb pain), treated with oploids. (Endone 5mg BD), tricyclic antidepressant (amitriptyline 10 mg tds) and antiepileptic (Neurontin 109 mg tds). Commenced participating in physiotherapy program and involved with pre- prosthetic training.

15/02/2012      Orthopaedics:

Amputation incision remained intact                         

Stitches out                           

  

Wound almost healed

Residual limb wrapped with an ace bandage to swelling and pain and re-applied every 3-4 hours

Mental State: Insomnia, silent rumination, and social withdrawal;              She has a fear of being seen in public.

Consulted with social worker.

22/02/2012                  Fragmin was discontinued.

No signs of DVT were observed.

Phantom limb pain: she remained stable on Paracetamol- Osteo 665 mg qid and Tramadol prn.

Min oedema of the stump w/peeling skin, no signs of infection.

Bowel management: Citrucel was discontinued. She started Coloxil with Senna one tablet bd and Dulcolax suppository prn.                             

Fluids, Electrolytes, Nutrition: The patient was on a regular diet.

Able to walk with rolling walker for short distance along the ward and use a wheelchair for long distance, but needs increasing assistance for stairs.                                         

Trained to wrap the stump with ace bandage.

Parents were educated about assistance with ADL’s.            

Vital sign with no abnormalities.

Discharge Plan           Warm compress, ice packs and massage are recommended for phantom limb pain.

To continue regular exercises as per physio program and dressings with ace bandage to shape the amputated limb for fitting with prosthesis. The patient is at increased risk of developing post-traumatic stress disorder (PTSD) or depression in the late period after the trauma.

Peer counseling or support groups to support her can be helpful.

The patient will be seen at the trauma clinic at 3.30 pm on 13/04/2012.

Medication On Discharge (Self-Administration):  Neuretin 100 mg qB h Paracetamol Osteo 665 mg qB prn,

Trazodone 50 mg p.o at bedtime, prm           

            

Laxatives prn

WRITING TASK: You are a charge nurse at the trauma ward of St. Agnus Hospital, Sydney. Using the information in the case notes, write a letter to a Community Nurse at Spirit Family Medical Practice, 12 Gar Street, Holy Hill, NSW, 2167. In your letter explain relevant social and medical histories and request the Community Nurse to visit Ms. Ling Wu after discharge to provide proper health management and assistance for this patient and her family.

Submit your OET letters for correction: (for a minimal fee)
https://goltc.in/oet-writing-correction/