CASE NOTE 9

You are Registered Nurse, working in Alphonsa Hospital, Sydney Australia

Read the case note and complete the task.

Today’s date: 15/07/19

Patient’s Name: Ryan Robinson
Age: 8 years DOB: 12/08/2011

 Patient history

 Baby born by cesarean section

 Mother had postpartum hemorrhage
 Normal birth weight, jaundice during newborn period
 Hospital admission in 2013 due to diarrhea and parents complained Hyperactivity,
psychiatric consultation in 2014
 Left wrist fracture in 2017 , plaster cast applied
 Lives with parents and siblings, father Diabetic

 Reason for admission:

 fever , Redness in left eye , watery discharge, itching
 On Examination: T: 101 degree Fahrenheit, PR : 98/min RR: 20/min ,watery discharge
from both eyes, edematous eye lid , difficulty in reading

Diagnosis: Bilateral Conjunctivitis

12/07/19

 Admitted to isolation ward

 Eye drop floxasin 0.1% qid
 Acetaminophen 500mg TID for fever
 Cephotaxim 5mg inj BD diluted with distilled water
 Informed parents to avoid sharing personal things with patient

13/07/19

 Continue medication
 Injection changed to tablet
 On examination watery discharge reduced , fever reduced , edema slightly present
 Patient restless and irritated , still ADHD present
15/07/19

 Patient complains of severe pain in both eyes. Blurred vision

 On examination : severe redness , watery discharge from both eyes and condition
worsened
 Temp : 104 degree Fahrenheit : tepid sponge and inj paracetamol given
 On blood test ESR: 85mm,HB 11.5 , total blood count increased.

 Advice for parents

 Separate siblings from Ryan

 Avoid using his personal things and avoid dust and pets
 Prevent exposure with sun and avoid strenuous activity with eyes
 Continue medications as per order

 Plan

 Arranged consultation with ophthalmologist at St Spirit Hospital, Melbourne and transfer

the patient to the hospital.

 Writing task

 Write a letter to the parents regarding home care management-: Mr Robinson , Northway
Street 07181 ,Sydney
 Write a letter to the school teacher regarding his current health status and need for leave :
Ms Maria St. Stephens upper school , Melbourne
 Write a letter to the ophthalmologist and explain his medical history. Dr.James John , St.
Holy Spirit Hospital , Melbourne to check his vision & for further management.