TASK 9 CASE NOTES – MARGARET GOLDSTEIN

Maggie Goldstein is a 61-year-old female Alzheimer’s disease sufferer currently admitted to

North Caulfield Private Hospital for a dislocated elbow after a fall at her aged care home.
Patient details

Name: (Mrs.) Margaret (Maggie) Goldstein

Age: 61 years
Marital status: Married
Family: Husband, Solomon (Sol) Goldstein aged 65, no children
Admission date: 8 November 2017
Discharge date: 12 November 2017
Admission diagnosis: Dislocated R elbow, early Alzheimer’s; progressing rapidly
Social background: Full-time care at Eventide Residential Aged Care, 333 Glen Eira
Road, Ripponlea, Vic. 3185. Husband lives nearby in Elwood;
Business Owner/Manager “Computers ’R’ Us”
Previous career: Computer programmer
Previous hobbies: Championship golf
Medical history: Obesity - Height 157cm/ Weight 90kg
HTN Alzheimer’s onset detected (11/2014) - no known close family
sufferers
Current condition: Ready for discharge back into full-time care

R elbow in cuff w sling; healing slowly

Skin intact
Uses wheelchair, transfers w. some assist

Continent of bowel/incontinent of bladder (10/11/2017)

Reluctant to wear disposable briefs
Requires assist w. showers and incontinence care.
Medications: oxycodone 5mg 3/dy to be continued as needed Atacand Plus
32/12.5 25mg/day Remeron 15mg/day
Management and progress: Medically stable
Discharge plan: Spouse will collect patient when discharged to transport back to
Eventide. Monitor healing of elbow. Monitor incontinence care.
Follow-up w. physiotherapist, appt 28/11/2017, 2pm, at Eventide

You are Charge Nurse at the hospital where Mrs. Goldstein was admitted 3 days ago for
treatment of a dislocated elbow. Using the information in the case notes, write a discharge letter
to the Supervisor at Eventide Residential Aged Care -- 333 Glen Eira Road, Ripponlea, Vic. 3185,
for discharge back into permanent full-time care.
In your answer:

• Expand the relevant notes into complete sentences

• Do not use note form
• Use letter format
The body of the letter should be approximately 180 - 200 words