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Case Note 22: Medical History

Ms. Elizabeth is a 75-year-old widow living in a nursing home who was recently admitted to the hospital after a fall and hip fracture. She has a history of hypertension, diabetes, bipolar affective disorder, and a previous suicide attempt. Since her surgery, she has experienced anxiety, depression, mood changes, and suicidal thoughts. She will be discharged back to her nursing home tomorrow pending a psychiatric consultation.

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364 views

Case Note 22: Medical History

Ms. Elizabeth is a 75-year-old widow living in a nursing home who was recently admitted to the hospital after a fall and hip fracture. She has a history of hypertension, diabetes, bipolar affective disorder, and a previous suicide attempt. Since her surgery, she has experienced anxiety, depression, mood changes, and suicidal thoughts. She will be discharged back to her nursing home tomorrow pending a psychiatric consultation.

Uploaded by

BINCY
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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CASE NOTE 22

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

 Widow lives in Victoria Nursing home


 Daughter Masia lives with husband settle abroad
 Recently quit smoking
 BMI 30: food preference , junk food , cheeses , spicy , red meat, sweets
 Son down syndrome [rehabilitation center]
 Mother died due to diabetic foot
 No other social involvement
 Grandfather : passed away , severe depression

4/7/2019

 Fall from upstairs


 Complained severe pain and swelling on left leg, difficulty to stand and walk
 Bruising on the forehead
 Nausea
 X ray done- Hip fracture
 Hip replacement surgery
 Post operatively analgesics and antibiotics
5/7/2019

 Bp 140/90mmHg, pulse 82b/m, spz-97


 Febrile 100 degree c
 Loss of appetite. On IV fluid
 Syrup aptivate advised
 Asked his preference
 Constipation: laxatives

7/7/2019

 Good bowel movement


 Refused movement from bed
 Depressed

8/7/2019

 Admitted to sit on bed


 Physiotherapy advised: pain , refused , advised to use walking stick , require home
visits
 Disoriented, aggressive
 Anxiety, fears of death
 Blood sugar: 420 mg/dl , human actrapid increased: 18-20-20

9/7/2019

 Severe anxiety, mood changes


 Suicidal thought, loss of interest and pleasure in activities
 Crying
 Difficulty to sleep
 Appetite : good , had full portion of offered meal
 Not following any exercise

Management

 Daily dressing using antimicrobial cream


 Suture to be removed after one week
 Low sodium diet
Medication

1. Amilodipine 10 mg [OD]
2. Carbomazepix 200mg [BD]
3. Paracetamol 500mg as need

10/7/2019

 Plan for discharge tomorrow to Nursing home (Victoria)


 Psychiatric consultation prior to discharge

Discharge plan

1. Advised dietary modification


2. Medication monitoring
3. Wound dressing and observe for signs of complications
4. Strict exercise with use of assistive devices

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.

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