Case Notes 01.4 – Nursing
TIME ALLOWED: READING TIME: 5 MINUTES
WRITING TIME: 40 MINUTES
Read the case notes below and complete the writing task which follows.
Today’s Date 14/09/2023
You are a community nurse assisting Dr. Peter Smith, GP, covering 3 satellite clinics in a remote mining area of Western Australia. The nearest tertiary hospital to you is 1250 km away in Perth or 2 ½ hours by air evacuation using the Flying Doctor Service. The nearest poly clinic is in Port Hedland with radiology and laboratory facilities but it is a 6-hour drive over dirt roads.
- Ammar Reuters
- DOB: 15/1/67)
- Divorced and lives alone
- Process Technician at a Copper Mine in the remote Pilbara region of Western Australia.
- Works on rotation with 6 weeks on location and 4 weeks off.
- Started his present rotation one week ago.
- Regular overseas holidays.
- Just returned from the Philippines 2 weeks ago after spending a 2-week vacation.
- Enjoys water sports: scuba diving, sailing
- Smokes 20 cigarettes/ day
- Drinks 14 units/week
- Walks half an hour every day.
- Hx of typhoid fever, (2015). In hospital for 6 days.
- Not on regular medication.
- No known allergy.
- Father died of natural causes at 85.
- Mother hypertensive and diabetic aged 76.
- Older sister treated for cancer breast when she was 40.
- Ammar feels unwell, lack of appetite, sense of weakness and lack of energy for 3/7
- Has reduced smoking to 5 cig/day and not drinking for one week.
- No vomiting but nauseating and passing motion normally.
- Patient looks tired, not jaundiced
- Weight 89 kg; Height 193 cm
- Pulse 84 regular, BP 130 /80, Temp 37.3° C
- CVS, RS are normal.
- Abdominal examination: Lax and mobile with no mass or rebound but tender rt. hypochondrium with no organomegaly.
Assessment and Planning
- Prodromal stage of liver disease or mood swings after changing his drinking and smoking habits.
- Advise low fat, low protein and rich carbohydrate diet.
- Order blood, urine and stool tests.
- Prescribe vitamins B complex tablet one TDS and essential forte capsules 2 TDS.
- Review in two days for results.
- Ammar is getting worse.
- Cannot tolerate foods; only drinks fruit juice and noticed that the urine is getting darker with chills and rigors.
- Temperature 39°C; looks jaundiced and dehydrated.
- Abdominal examination shows palpable, tender liver.
- No ascites
- Investigations show normal stool and 2+ urobilinogen in urine test. Leukocytoses with increased serum bilirubin and deranged liver enzymes (ALT And ALP) in blood tests.
Assessment and plan
- Start IV fluids and medicate Rocephin one-gram IV BD and Flagyl 500 MG TDS
- Contact Flying Doctor Service for urgent US examination or evacuation.
- Result of US shows enlarged liver 20 CM with a 10 x 10 cm cystic lesion in the Rt. Lobe of liver
- Liver abscess diagnosed.
- Arrange referral to surgeon in Perth by Flying Doctor Service which will be escorted by you in person.
- Urgent assessment required including ultrasound guided drainage.
Refer patient to the Surgical Registrar via the Emergency Department of Perth General Hospital, 268 Brisbane Rd Cottesloe, Western Australia 6542.
In your answer:
- Expand the relevant case notes into complete sentences
- Do not use note form
- Use correct letter format
The body of your letter should be approximately 200 words. Use correct letter format.