CASE NOTE 19

You are a charge nurse at Holy Spirit Hospital

Mr. Johnson is a Patient in your care; He is going home from hospital. Read the following discharge
summary and complete the writing task.

Name: Mr. Johnson

Age: 56 years
DOA: 06/07/2016
DOD: 31/07/2016

Chief complaints
 Breathing Difficulty
 Fever
 cough – with sputum

Diagnosis

 ARDS and H1N1

03/07/16

OPD

 Started antibiotics and antipyretics

 Advised to review after 5 days
 Body weight : 70kg

06/07/16

 Severe breathing difficulty , High fever

 Came to emergency by ambulance
 Started oxygen 5 litter via face mask
 ABG Report Showed Respiratory acidosis
 X- ray , CT- Scan shows partial collapse of lungs
 Antibiotic started. Piptaz 500 mg 1-0-1

07/07/16

 Condition worsened
 Intubated with 7.5 ET tube.
 Suspected for H1N1 -swab sent
 Repeat CT-scan shows complete collapse of lungs
 Discussed patient condition with family
  08/07/2016
 ABG, APTT 6th hourly monitoring
 NG feed started with Nepro- HP
 Chest physiotherapy started
 Change position every 6th hourly
 Family counseling given

09/07/2016

 VAP developed
 Antibiotic changed to Inj . Meropenem 1gm 1-1-1

23/07/2016

 Infection marker reduced.

 Repeat chest X –rays shows slight improvement in lungs function
 GCS is 8
 Tracheotomy done

26/07/16

 ABG report normal ,

 SPo2 maintain 98%
 NG feed continue, but wife afraid to give feed at home, need education
 Tracheotomy care given

28/07/16

 Patient extubated from tracheal ventilator

 Started oxygen 5 lit through T piece
 Antibiotic injection changed to tablets

30/07/2016

 Plan for discharge tomorrow

 O2 reduced to 1ltr
 Vital signs normal.
 No fever, cough
 Hb 8.6, advised iron rich food
 Body weight 58kg
 Low sodium, protein rich diet advised
 Constipation for 2 days, include fibers
Social history

 Married and lives with wife.

 Have 2 children both are married
 Chronic smoker and drunkard.
 No social contact
 patient is allergic to milk

Past Medical History

 HTN since2000
 Tablet amlong 5mg

Current Medication

 Tab.Meropenem 1-0-1
 Tab. Pan 1-0-0
 Tab.pct (sos)

Discharge plans

 Monitor and continue all prescribed medication

 Chest –physiotherapy every 6th hourly
 Breathing exercises
 Continue NG feed as per the dietician‘s order. Assess nutritional status periodically
 If any problem related to breathing, please contact pulmonologist. Dr. Trump.
 Appointment is scheduled with pulmonologist after 10 days

Writing task

1. Write a letter to the pulmonologist, Dr. Trump,3 rd Main ,Brisbane, Australia to assess his progress
and for necessary management. Include all relevant medical history in the letter

2. Write a letter to community health Nurse regarding follow up care .Include relevant medical history
and discharge plan. You can send letter to the Community Health Nurse, Community Health Center ,
Oakland Community

3. Write letter to dietician, Brisbane town No.462, Australia and request for nasogastric feed
guidelines and diet plan