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Case Note 24: Patient Details

Mr. Clint George, a 65-year-old widower with diabetes, hypertension, and a history of stroke, was admitted to the hospital for appendicitis. He underwent an appendectomy but his wound became infected, requiring a change in antibiotics. By his discharge date of April 20th, his condition had improved except for some walking difficulty from his prior stroke. As part of his discharge plan, the nurse is writing a letter to request physiotherapy services to enhance his mobility.

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501 views3 pages

Case Note 24: Patient Details

Mr. Clint George, a 65-year-old widower with diabetes, hypertension, and a history of stroke, was admitted to the hospital for appendicitis. He underwent an appendectomy but his wound became infected, requiring a change in antibiotics. By his discharge date of April 20th, his condition had improved except for some walking difficulty from his prior stroke. As part of his discharge plan, the nurse is writing a letter to request physiotherapy services to enhance his mobility.

Uploaded by

BINCY
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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CASE NOTE 24

Time: Reading – 5 minutes, Writing- 40 minutes

You are a registered nurse in Angel Mary Hospital. Mr Clint George is a patient in your care.

Patient Details

 Patient Name: Mr Clint George


 Age: 65years
 Address: William Cresent,Smith Town,0415831565
 Diagnosis: Appendicitis (appendectomy)
 Date of Admission: 10/04/2019
 Date of Discharge: 20/04/2019

Presenting Illness:

 severe abdominal pain

Past Medical History :

 Diabetic and Hypertensive {10 years}


 On tab metformin 500 mg and alphadopa 250 mg
 H/O tonsillectomy {last year}
 H/O CVA -2018 { rt.side paralysis ,slurred speech}
 Allergic to Pandine Forte
 ORIF {Rt leg} -2011, walks with limb (aid -stick)

Social History:

 Widower , Retired postman


 Lives alone in a rental flat, one daughter married
 Smoker {30 yrs}, crazy for sweet foods
Treatment And Progress:

10/04/2019:

 CBC- WBC elevated, RBS – 300mg/dl , USG- inflammed appendix

11/04/2019:

 surgery done , post op medications – inj diclophenac and Taxim 1gm{ IV BD}
 Wound management , daily RBS monitored,

13/04/2019:

 Wound oozing noticed-itching and redness around wound site


 Medication changed to Augmentin,wound dressed

15/04/2019:

 still wound leakage noticed-dressing continued

19/04/2019:

 condition improved,except - slight walking difficulty ,wound healing started,


RBS -130mg/dl,
 Started mobilization, assisted in showering and personal care

20/04/2019:

 Ready to be discharged
 Temp: 98.6 degree celcius
 RR:20brths/mt
 Pulse: 80bts/mt
 BP: 120/80 mm Hg

Discharge Plan:

 Refer to physiotherapist
 Proper instruction for mobilization
 Provide walking aid
 Slight exercises needed
 Refer to community health nurse
 wound dressing
 Soft diet and fluid intake
 Need to monitor blood glucose level regularly
 Assistance for showering and daily activities
 Monitor medication compliance
 Follow-up after 1 week

TASK
Using the information in the case note write a letter to The Physiotherapist Home,Jones Street ,Ekibin to
request physiotherapy services for Mr. George to enhance his mobility.

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