CASE NOTE 23

You are charge nurse in City Hospital, Melbourne. Mr.Samuel Chakole is a patient in your care

Name: Samuel Chakole

DOB: 14/07/1945
Address: 1/86 East Victoria Park WA, Melbourne, Australia.
Phone No- +61865934701

Social Background

 Lives with his wife, 2 children live in London they visits occasionally, Retired professor
 History of smoking 5 packs/day since 2000
 Income from age pension and gardening.
 Mrs. Chackole has age related problems& Memory loss

02/08/2013
 DM on metformin
 Allergic to sulfa drugs

07/10/2015
 PTCA done. On clopidogrel and Ecospirin Hypertension [B –Blocker ]
 Food poisoning [following ingestion of prawns]

10/06/2016
 Admitted with intermittent fever
 LFT- elevated
 Yellowish discoloration of sclera, nails & Skin .
 Diagnosed as jaundice
 Nausea, vomiting& hematemesis.
 Gradual weight loss.
 USG abdomen –liver cirrhosis.
 Steroids injection, Inj vitamin K OD for 3 days, udilive 150mg twice daily.
 Decrease fat intake.
 Alcohol restriction.

03/12/2016
 Admitted with fever fatigue, nausea, vomiting, leg swelling, increased abdominal girth, and
breathlessness
 Vital signs – T-100degree F , BP -150/90, Pulse -102,
 No headache, No unconsciousness.
 Oxygen 3 lit through nasal prongs started,
  USG showed ascitic fluid collection
 Increased liver enzymes.
 Bilurubin -75, ALK – 250, AST – 63, ALT- 80.
 USG guided fluid taping done – 700 ml drained.
 Samples send for glucose, routine, Culture, albumin, total protein and cytology.
 Antibiotics started.
 Fluid restriction less than 1 lit/day.
 Physical weakness increased
 Platelet 30000, 4 unit platelet transfused
 Advised to withhold ecospirin & clopidogrel
 Health education given regarding cessation of smoking and alternative measures to quit
alcoholism

04/12/2016
 Platelet increased to 70000.
 3unit platelet transfused
 Referred to Gastroenterologist
 End stage liver disease diagnosed.
 Regular monitoring of GRBS done.
 Wife worried about patient condition and requested for discharge.

05/12/2016

 Platelet 120000
 USG repeated Ascetic fluid 200 ml noted.
 Poor prognosis explained
 Wife requested for discharge and requested to send patient rehabilitation center.
 Wife and patient require only symptomatic management.

Discharge Plan

 Symptomatic management.
 Follow up with gastroenterologist
 Fluid restriction less than 1 lit/ day
 Alternative days PT, PTT, INR checking
 Personal care assistance
 Monitor medication.
 Avoid fatty foods.
 TASK

1 Using the information given the case note, write a letter to Mr. stanly Dsouza , Director of golden
rehabilitation center ,Australia who is responsible for the palliative care of Mr. chakola after discharge.
Add all medical and social data which is relevant.

2 Write a letter to Dr. Rohaly srivastava Gastroenterologist who visits golden rehabilitation center to
evaluate Samuel’s health condition and to provide follow up treatment.