CASE NOTES 5

Read the case notes below and complete the writing task which follows: You are
a community nurse visiting the patient daily.

Patient Details
Name: Catherine Edith
Age: 28 yrs
Occupation: Restaurant manager
LMP: 15/07/2019
Current Doctor: Dr. Shaw (gynecologist)

Present History (01/10/19)

 1st trimester – 10th week
 Anxiety, depression due to previous abortion, weight loss
 Decreased food intake (Hb-9 mg/dl) hyperemesis
 HbA1C just below boarder line (6.5)
 Weight -45 kg (pre pregnancy-46 kg)
 Skip the meals very often, decreased fluid intake
 Food preference : junk food, likes to eat more baked food items
 Needs education on proper diet during pregnancy
 any nutritional deficiency disorder

Social History
 Next of kin: Husband (business)
 Elder sister baby- Down’s syndrome
 Lives in Sydney, Orange, Peanut garden, NSW 2001
 Rented house, two storey building
 Married 5 years
 Caring mother, limited friends, occasional drinker

Past History
 Abortion -1
 Infertility treatment – 3 yrs
 Appendectomy – 2005
 Flu vaccination 5 months back
 Migraine (Tab. Grenil 100 mg)
 Rt. Oophorectomy – 2016
Treatment Plan
 Patient urgently needs information on eating patterns, strong encouragement
for improving diet.
 Advice on reduce or eliminate drinks
 Counseling therapy (anxiety, depression )
 Requires advice from dietician
 Nutritional assessment
 Psychological consultation with husband and mom
 Need to be educated regarding diabetes and importance of diabetic diet

Writing Task

 Using the information in the case notes, write a letter to dietician,

medical center, Brisbane, NSW 4000.
 Using the information in the case notes, write a referral letter to Dr.
Samuel Philip, Psychologist. Finders Medical Centre, Bedford Park,
5042, Sydney.