Task 2 Case Notes: Robyn Harwood

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

Time Allowed: 
Reading Time: 5 minutes
Writing Time: 40 minutes

Today’s Date
12/07/12

You are Sonya Matthews, a registered nurse at the Spirit Hospital. Robyn Harwood
is a patient in your care. Read the case notes below and complete the writing task
which follows.

Patient Details

Name: Robyn Harwood

Address: 8 Peach St, New Farm
Phone: (07) 3397 2695
Date of Birth: 4 February 1951

Social Background

Marital status: Widow. No children. Lives alone

Next of kin: Megan Mack (Niece)
Niece lives with husband in Sydney who works as software engineer for Google
Australia. Sister died recently. No other relatives.

Medical History

Diabetes Mellitus Type 2

Metformin 500mg mane

Diagnosis

Right partial rotator cuff tear

Presented to Spirit hospital with pain and weakness in the right shoulder, especially
when lifting arm overhead.
Descending stairs at home and slipped, falling onto outstretched arm.
Xray and MRI showed a partial rotator cuff tear.
Orthopaedic surgeon discussed surgery. Patient prefers to try non-surgical
treatment.
Date of admission: 30-06-2012
Date of discharge: 12-07-2012

Treatment

Ibuprofen orally QID

Cortisone injections
Daily physiotherapy

Nursing Care Needs

Needs blood glucose level monitoring 4 hourly

May be elevated because of cortisone
Needs assistance with shower and housework
Orthopaedic review on 01/08/12

Writing Task

Using the information in the case notes, write a letter to the Nursing Director Ms.
Jenny Attard of the Blue Care Agency, requesting visits from the home care nurse.

In your answer:

 Expand the relevant case notes into complete sentences

 Do not use note form
 The body of the letter should be approximately 180~200 words
 Use correct letter format
Ms. Jenny Attard
Nursing Director
Blue Care Agency

12 July 2012

RE: Ms. Robyn Harwood (DOB: 04 February 1951)

Dear Ms. Attard,

I am writing this letter to request for home visits for Ms. Harwood, who is to be
discharged today after experiencing right partial rotator cuff tear. She needs your
assistance.

On 30 June, Ms. Harwood presented to our facility with complaints of pain and
weakness on her right shoulder from a fall injury onto an outstretched arm while
she was descending stairs. XRAY and MRI then indeed confirmed the diagnosis, so
our orthopedic surgeon discussed surgery, but she only chose to undergo non-
surgical interventions. This includes ibuprofen four times daily, cortisone injections,
and daily physiotherapy. It is also noted that she has diabetes mellitus type 2 that is
managed by her taking of metformin, 500 mg in the morning.

You are requested to render care for Ms. Harwood at home. Her treatment might
cause other problems because her cortisone injections can possibly increase her
blood glucose levels, so you need to monitor it every four hours. She has to be
assisted with taking shower and other household chores because she lives all by
herself. Although she has a niece, she lives in Sydney. Finally, there is an orthopedic
check-up that you have to facilitate this 01 August at our hospital.

I am hoping for Ms. Harwood’s fast recovery. Please ask me for any queries.

Truly yours,

Ms. Sonya Matthews

Registered Nurse
Spirit Hospital

WORD COUNT 200