Case Notes & Analysis 5

This case notes will be used for writing today’s letters for correction. Before you proceed to writing this letter on the writing page, please read this case notes and answer the questions that below:



Read the case notes below and complete the writing task which follows.


Patient Details

Betsie Anderson, 89, full code
Allergy to iodine (flushing, rash)
Lives in Woodside House nursing home facility; Widowed

Medical Background:

  • Hypothyroid
  • Dementia
  • GERD
  • Constipation
  • ORIF R Hip 2017

Recent History:

  • Pt confused, oriented to person only
  • Increased somnolence
  • New onset urinary incontinence
  • Loss of 6 pounds in one week
  • Low grade fever
Admission Date:
Discharge Date:
Urinary Tract Infection
Hospital Information:
Norfolk and Norwich University Hospital

ED record

  • Vitals- Temp 38.3C, HR 119, RR 23, O2 Sat 91 on RA
  • Labs- WBC 15.2 mg/dl UA + bacteria. Urine & Bld Cx pending
  • Pt given acetaminophen 650mg po x1 in ED
  • Started on IV ciprofloxacin

Nursing Care:

  • Daily assessments including LOC, BP
  • Assist w/ ADLs
  • Frequent toileting with proper hygiene
  • Assist with increasing activity, starting PT
  • Orthostatic BP
  • Transition during position changes slowly
  • Oriented now, no longer confused
  • Pt ready for discharge

Discharge Medications:

  • levothyroxine 200mcg morning
  • Protonix 75mg daily
  • Colace 100mg morning
  • Ciprofloxacin 250mg PO Q12H x14D
  • Multivitamin with calcium night
  • Aricept 10mg QHS

Discharge Plan:

  • FU with GP Dr. Alex Rose in 2 weeks
  • Repeat UA and labs in 2 weeks
  • Continue daily vitals and assessment
  • Observe for signs of dehydration & orthostatic BP

Equipment required:

  • walker, cane, bedside commode

Writing Task

Using the information in the case notes, write a letter to Ms. Stella Howard, head nurse for Woodside Nursing House in Norwich 142 Woodside Rd, Norwich where patient will return after discharge.

In your answer:

  • Expand the relevant notes into complete sentences
  • Do not use note form
  • Use letter format
  • The body of the letter should be approximately 180–200 words.

Now take this Case Notes Analysis and proceed to Letter Writing

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Written by Biju John

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