Case Notes 01.4 Ammar Reuters

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.

Notes:

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.

Patient History

• 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.

Drug History

• Not on regular medication.
• No known allergy.

Family History

• Father died of natural causes at 85.
• Mother hypertensive and diabetic aged 76.
• Older sister treated for cancer breast when she was 40.

12/09/2023

Subjective

• 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.

Objective

• 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.

14/09/2023

Subjective

• Ammar is getting worse.
• Cannot tolerate foods; only drinks fruit juice and noticed that the urine is getting darker with chills and rigors.

Objective

• 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.

Writing Task:

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.