Case Note 22: Medical History
Case Note 22: Medical History
Case Note 22: Medical History
You are a charge nurse in good shepherd hospital .Ms Elizabath is a patient in your care
Name : Ms Elizabath
Age : 75 Years
Medical History:
Hypertension ,10 years,
Diabetes Type 2 Since 2000, insulin human actrapid 16 unit, 18unit, 18 unit
BPAD diagnosed at the age of 30, medication non compliance noted. Treated with ECT.
on medication
Failed suicidal attempt at the age of 42 years
History of Chickenpox at childhood
Hospitalization- food poisoning before Five Years
Childhood : inferior, introverted , hesitant to go school
Gained weight : 5kg over 2 months, recently
Social History
4/7/2019
7/7/2019
8/7/2019
9/7/2019
Management
1. Amilodipine 10 mg [OD]
2. Carbomazepix 200mg [BD]
3. Paracetamol 500mg as need
10/7/2019
Discharge plan
Task
1. Using the information in the case note write a letter of referral to Dr. Mathew Philip,
psychiatrist royal Perth hospital, Sydney for assessment and further treatment. He visits
good shepherd hospital twice in a week.
2. Write a letter of referral to Ms Agnes Joy, dietician, good shepherd hospital Sydney for
dietary advices to manage diabetes and obesity.
3. Write a letter of referral to physiotherapist, physiotherapy center, Sydney for explaining
the use of assistive devices and to assist him in physical exercise to improve his
mobility.
4. Write a letter to the in- charge of Victoria nursing home who will be responsible for
Elizabeth’s continued care.