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Discharge Summary for Beryl Casey

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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164 views3 pages

Discharge Summary for Beryl Casey

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.

Uploaded by

Gayle and Beyond
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 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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