CASE NOTE 25

You are Nancy Rodrigues, a registered nurse working in the Royal Hospital .Martin Dsouza is your
patient .Read the case note given below and complete the writing task follows

Patient’s name: Martin Dsousa

Age: 80
DOA: 03 October 2018
DOD: 21 November 2018
Diagnosis: total hip replacement

Past medical history

 Parkinsonism
 Diabetes since 2012
 Cataract surgery in 2005
 Hernia repair in 2000
 Osteoarthritis
 Memory impairment
 Left side weakness
 Walks small distance with stick
 Slurred speech

Social history

 Retired accountant
 Widower
 Lives alone
 Smoker for 16 years [5-10cig/day]
 Son works as teacher

Medical history

 Metformin 500 mg BD
 Usually takes eye drops
 Levodopa 5 mg
 Clopivas 75 mg
03 October 2017

 Slipped in the bathroom

 Swelling and pain on the hip region
 Elevated BP noted from the hospital
 X- ray --hip fracture
 Hemoglobin -7 mg/dl; 2 unit blood transfused

05 October 2017

 Leakage on dressing site : redressed

 No infection noted
 Reported increased pain
 Fentanyl patch applied
 Tolerated soft food
 Hemoglobin repeated 8 mg/dl

Nursing management

 Daily dressing exercise initiated

 Mobilized at bed edge
 Reviewed by dietician
 BP controlled

Discharge plan

 Ongoing monitoring for blood sugar and pressure

 Continue usual medication
 Non weight bearing exercise
 Need daily dressing by a nurse and check for any complication
 Review with dietician
 Review after 2 weeks with FBE
 Personal care

Writing task

1. Using the information in the case note, write a letter to physiotherapist Mr. Alfred for daily home visit
and assist him to do exercise.

2. Using the information write a letter to community health nurse Mrs Maria who is responsible for his
continued care.