CASE NOTE 17

Albert Dsouza has been admitted to perth hospital, Melbourne.

You are a senior nurse.

Patient details

Name: Albert Dsouza

Age: 45 Years
DOA: 18/07/18
DOD: 23/07/18

Social History:
 Lives alone
 Widower
 Next to kin: sister.
 Food : McDonald
 Chronic smoker , use 10 cigarettes/day
 Attends club meeting every Friday
 Leads sedentary life

Hobbies :
 Reading and Listening music.

Patient history

18/07/2018

 Patent referred from community center with

 Chest pain radiated to shoulder
 Breathlessness
 abdominal pain , started 1 week ago
 Weakness
 Increased sweating

Investigations

 ECG done – MI confirmed

 Cardiac triage – showed positive report.
 HB- 7.8
 Urine routine – normal
 RBC – 2Laks
 USG- renal stone-in right kidney, reference to nephrologist
Treatment

 Thrombolysis with streptokinase

 Pain reduced
 O2 administration via nasal tubes
 Head end elevation
 Vital signs normal.
 Low sodium, low sugar diet advised

Medical History

 HTN since 2010 on amlodipine 5mg OD

 Cellulities on the right foot, daily wound dressing on right foot
 Diabetes since 2014 on conservative management.

Discharge plan

 Routine wound care.

 Continue antibiotics and other medications.
 Blood sugar checking 3 times /week.
 Maintain BP chart.
 Reference to dietician.
 Review visit after 3 weeks in OPD at 10 am with cardiologist.
 If any complication contact local GP

Writing Task

 Using information given in the case note write a referral letter to his community health nurse,
Alexandria, Melbourne 3051. Who is responsible for his continued care.