Task 20: Today’s date: 19/02/2012

You are Louise Nagatani, a registered nurse in the Coronary Care Unit at a General Hospital. Nasser Ali is a patient in your care.

Discharge Summary

Name: Nasser Ali

Address: 1052 Moorvale Rd, Moorooka, Phone: 046538762, Date of Birth: 4 February 1964, Date of admission: 09/02/2012

Diagnosis: MI,  Date of discharge: 19/02/2012,  Name of Surgery:Angioplasty

Reason for admission:  Patient arrived at the hospital via ambulance 10 days ago suffering from acute Sub sternal chest pain radiating to left arm.

He complained of severe chest pain, pain in jaws and left arm, diaphoresis, dizziness and shortness of breath.

Patient has been diagnosed with myocardial infarction. Condition has now stabilised, however, he appears restless and worried about his condition. He is overweight and is a smoker.  He has high blood pressure.

Treatment:  Sereptolunanse, anticoagulants and anti-cholinergic drugs.

Continuous ECG monitoring, angioplasty on 10/02/2012

Post-surgery physiotherapy Karvea 150mg daily 1⁄2Aspirin  daily

Social History:  Family are refugees from Afghanistan arrived by boat in Australia in 2010.

Marital Status: Married, seven children. Aged 6 months to 22

Next of kin: Fatima Ali (Wife)

Employment: Nasser works as a Taxi Driver, Fatima: Housewife

Accommodation: Living in rental flat, No family doctor

Language: Dari. Nasser attends TAFE English classes but only has basic English conversational ability.

Discharge Plan: Follow up appointment made with cardiologist, Dr R Lang, Hospital Outpatients 2pm 26/2/2012. Order medications from hospital pharmacy – Explain usage and stress the importance of taking medication regularly as directed.  Arrange for dietician to provide dietary advice

Discuss importance of giving up smoking and provide advice on available quit smoking programs

Advice patient to continue with the exercise program recommended by the hospital physiotherapist, particularly deep breathing exercises with Triflo. Arrange for a community social worker to provide a support service to the family to ensure a smooth transition back to normal life

WRITING TASK: Using the information in the case notes, write a letter to the social worker, Sarah MacDonald, Annerley Community Centre, 1122 Ipswich Rd Annerley, 4121 explaining the patient’s situation and needs.

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