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Case Note 12

This case note describes a visit by a community health nurse to assess a 4-year-old boy named Albin Charlie who has autism. He recently had a fever and swelling after receiving the influenza vaccine. His developmental milestones were delayed and he has ongoing speech, social, and behavioral issues. His mother, Ms. Georgia, is depressed and struggling financially and emotionally to care for him and her other children since the death of her husband 10 months ago. The nurse's plan is to refer the child to a pediatrician and psychologist for evaluation and the mother to a social worker for counseling and support.

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3K views3 pages

Case Note 12

This case note describes a visit by a community health nurse to assess a 4-year-old boy named Albin Charlie who has autism. He recently had a fever and swelling after receiving the influenza vaccine. His developmental milestones were delayed and he has ongoing speech, social, and behavioral issues. His mother, Ms. Georgia, is depressed and struggling financially and emotionally to care for him and her other children since the death of her husband 10 months ago. The nurse's plan is to refer the child to a pediatrician and psychologist for evaluation and the mother to a social worker for counseling and support.

Uploaded by

BINCY
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
  • Case Note Details: Documents the community health nurse's visit details, patient’s background, and medical history.
  • Plan and Task Details: Outlines the management plan and tasks assigned to support the patient and family.

CASE NOTE 12

You are a community health nurse, visited Mrs. Georgia’s house for under 5 assessments.

20/07/2018

 Patient Name: Albin Charlie,


 Mother: Mrs. Georgia
 Age: 4 years, under weight – 10kg
 Vaccination record: up to date
 Diagnosis: Childhood Autism.

Chief Complaints:
 Patient developed soreness,
 Swelling at injection site, and low grade fever after the influenza vaccine which received
on 19/07/2018
 Extent anger and hyperactivity,

Medical back ground


 Developmental delay – crawl at 10 month
 Walked – 2 years
 Poor speech and poor concentration noticed at 2year
 Showed interest on playing guitar
 No history of fall
 History of viral fever at age 2.
 History of hospitalization –injury to hand and leg [self injury]

At 6 month
 Social smiling absent
 Lack of eye contact
 Not responded to name
 Poor visual tracking
 Repetitive movement
 Not mimics sound
At 15 month
 Made eye contact responded to sound and familiar voices
 Follow objective visually.
 Used gesture to communicate
 Absence of sound or words

At age 2
 Doesn’t use gestures
 Walks on his toes
 Doesn’t use two words phrase by 24 months
 Show lack of slang
 No verbal or social skills
At 3 Age
 Absence of eye contact
 Didn’t respond to name
 No interest in social activities
 Physical contact with siblings and mother
 Not expressed feelings
 Sitting and crying alone
 Not answer questions properly.
 Words repetition.
 Reversed pronunciation noted.
 Not laugh for jokes.
 Irritable with small changes in routine.
 Hyperactive.

Family History
 No family history of autism. No history of fall
 Ms Georgia consumes alcohol, increased during pregnancy. Lives in flat with 3 children -
4 year old, 2 year old, 6 months. No contact with family members. Intercaste marriage.
 Father of child died 10 months ago in an accident
 Financial crisis: searching for income generating activities
 Depressed, not talks well due to her elder sons health condition
 Anxious about his anger, speech delay, decreased social interaction.
 Mother unable to take care other children and plan to send Alfred to rehabilitation center:
need help to enquire about the admission and routines in the sender.
 Depends on neighbors for any help

Plan
 Arrange psychologist’s and pediatrician’s service: reference to social worker
 Management for low grade fever and malnourishment

Task
 Using the information given , write a referral letter to psychologist , 41 vulture street ,
WA Brisbane , 4101 requesting counseling for Mrs Georgia .

 Write a referral letter to Dr. William Richard, pediatrician 41 vulture streets, WA


Brisbane, 4101 for an assessment and management of the child’s current health status .

 Write a letter to social worker for assistants to Mrs Georgia to lead a healthy social life.
Social worker, Vulture Street, WA Brisbane.

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