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    Beryl Casey Case Note

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    Gayle and Beyond
    Mrs. Beryl Casey, a 72-year-old widow, was admitted to the hospital after fainting and fracturing her left femur. She underwent a left hemiarthroplasty and made steady progress in her mobility and activities of daily living over the following days. The case notes provide her medical history, treatment details during her hospital stay, and discharge plan for her transfer to a rehabilitation center.

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    Beryl Casey Case Note

    Uploaded by

    Gayle and Beyond
    131 views3 pages
    Mrs. Beryl Casey, a 72-year-old widow, was admitted to the hospital after fainting and fracturing her left femur. She underwent a left hemiarthroplasty and made steady progress in her mobility and activities of daily living over the following days. The case notes provide her medical history, treatment details during her hospital stay, and discharge plan for her transfer to a rehabilitation center.

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    Mrs. Beryl Casey, a 72-year-old widow, was admitted to the hospital after fainting and fracturing her left femur. She underwent a left hemiarthroplasty and made steady progress in her mobility and activities of daily living over the following days. The case notes provide her medical history, treatment details during her hospital stay, and discharge plan for her transfer to a rehabilitation center.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    131 views3 pages

    Beryl Casey Case Note

    Uploaded by

    Gayle and Beyond
    Mrs. Beryl Casey, a 72-year-old widow, was admitted to the hospital after fainting and fracturing her left femur. She underwent a left hemiarthroplasty and made steady progress in her mobility and activities of daily living over the following days. The case notes provide her medical history, treatment details during her hospital stay, and discharge plan for her transfer to a rehabilitation center.

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    Case Notes: Beryl Casey

    WRITING SUB-TEST
    TIME ALLOWED: READING TIME: 5 MINUTES
    WRITING TIME: 40 MINUTES
    Read the case notes below and complete the writing task which follows.
    Notes:

    Patient: Mrs Beryl Casey (DOB: 21/11/1941) is a 72-year-old woman who


    is being discharged from hospital to a rehabilitation centre.
    Marital status: Widowed (recently)
    Family: 2 children - son lives locally & daughter interstate.
    Social: Lives alone in 2-bedroom house with stairs to entrance.
    Son (married, 2 children - 6 & 8) lives 20 minutes away - visits
    twice a week.
    Enjoys gardening.
    Medications: Anti-hypertensive (Ramipril) 10mg
    Admission date: 4/02/14 at 1200hrs
    Fainted getting out of bed & fell to the floor, Found by son
    2 hours later.
    Diagnosis:X-ray - fractured left neck of femur (# L NOF) post fall
    Treatment: Left hemiarthroplasty (Austin Moore hip replacement);
    general anaesthesia
    Incision closed with staples & 2x Exudrain
    Post operation:
    • Intravenous (IV) therapy: 3 units packed cells - with IV Lasix
    (furosemide) 40mg therapy after each (intraoperative & post op)
    • Maintained IV therapy for 36hrs, then ceased and oral fluids
    encouraged
    • Intravenous antibiotics (IVABs) - Cephazolin 1g t.d.s. for 3/7 - course
    completed
    • Vital signs: BP hypotensive - 95/60, other obs. within normal limits
    Anti-hypertensive medication reviewd by Dr - Dose + now Ramipril
    5mg daily
    • Pain management: Patient-controlled analgesia (PCA) with Fentanyl
    for 36hrs -
    pain relief - satisfactory, Commenced oral analgesia 36hrs post op +
    Panadeine or
    Panadol 4/24 pm, Max 4 doses/24hrs
    • Wound management: Dressing
    Total of 600ml haemoserous fluid discharge from Exudrains over
    24hrs
    Drain tubes removed 48hrs post op (Day 2)
    Alternate staples removed Day 5 and dressing changed

    Mobility & activities of daily living (ADLs):


    Day 2 Sitting out of bed (SOOB) short periods, full assistance
    Day 3 Mobilising with pick-up frame (PUF) & 2-person assist
    Day 4 Uneventful
    Day 5 Mobilising short distances with PUF & 1-person assist
    Abduction pillow when resting in bed (RIB)
    Anti-embolic stockings in situ for 14 days
    ADLs - full assistance
    Day 6 Uneventful day
    Preparing for discharge

    Discharge plan:
    Day 7 (1100hrs) Discharge to the Rehabilitation Centre
    Discharge medications - Ramipril 5mg daily, paracetamol 1g
    qid prn
    Family to be notified of transfer
    Hospital transport arranged for 1100hrs
    Day 8 Repeat check of hemoglobin (Hb) levels
    Monitor BP b.d., for 3/7, due to adjustment in anti-hypertensive meds
    Assess for rehab therapy (Inpatient & on return home)
    Day 10 Removal of remaining staples, wound can remain exposed
    afterwards

    Writing Task
    Using the information given in the case notes, write a discharge letter to the
    Nursing Unit Manager, The Rehabilitation Centre, Waterford.

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