TASK 55

You are a registered Nurse at Geriatric Assessment and Rehabilitation Unit MS Sanithy Lionel is a patient admitted in the ward where you are a Charge Nurse

Patient Details           Name  :Sanithy Lionel Age: 82 Years          

Family :Married, Lives with husband

2 daughters and 3 grandchildren live in the same area

Medical History: H/o DM diagnosed 2002 Metformin 850mg/day.   Osteoarthritis diagnosed 2005, Voltaren

Visits her GP regularly.         

Complaint with diet, medication and exercise regime

Recent Medical history 27/10/2017:               

Onset of tenderness, swelling and pain in R lower leg last night

R and L leg pain swelling itchy burning sensation both legs swollen and flaky.     Ulcer on R leg excdates

Rigor, last night.          Temp 37.7 , BP 132/82 RR32 HR 80.  Referred to Dr.Dean Mills Department Head

Geriatric Assessment and Rehabilitation Unit for urgent assessment

Diagnosis : cellulitis

28/10/2017                 

Started penicillin IV               

Paracetamol tab                      

Panadol for pain, inj lasix

Complaints of pain      Rigors, swelling stabled         

Itchiness decreased limited burning sensation

Cleaned ulcer dressing done

29/10/2017      Observations redness of eyes and swollen puffy face Wounds red less itchy

Still has burning sensation and edema No fever.       

Patient allergic to penicillin changed to ceplax IV

30/10/2017      No redness of eyes decreased face swelling and puffiness Ulcer clear fluids drained

Changed injce plax to tab cepalax, Tab peracetamol continued

01/11/2017                 

Fluids clear edema reduced itchiness reduced No fever or rigors

Dressing done by nurse Continued medications

Discharge Plan           Continue all medications as prescribed Monitor for side-effects.      Monitor L&R leg for further complications. Dressing should be done regularly by a practice nurse Report local GP if any complications. Include the referral letter from Head of Geriartric Assessment and Rehabilitation Unit, Dr.Dean Mills to her local family G.P.          Review in Out Patient Department after 5 days

Writing Task Using information in the case notes write a referral letter to the Practice Nurse at Newtown Medical Centre regarding MS Lionel, include present medical history and plan.

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