ble Noo | ber WRITING: NURSE /DOCTOR Time Allowed: 40 minutes Read the case notes below and complete the writing task which follows: Patient; DoB: ‘Marital status: Family: First admitted: Discharge date: Diagnosis: Medical History: Background: ‘Management and Progress: Susan Surandon 417-7-90 Single Only child. Parents are still married and living together. Pt. is student in the 10th grade. 13.9.08 Patient did not present to ER until 13.9.05, at which time she displayed signs of peritonitis and septic shock with a fever of 39°C. 18.8.05 Ruptured appendix Peritonitis Pt received adenoidectomy in 1987. Meds: Pt. takes methylphenidate 10mg bid for ADHD. May be continued. «1 Denies EtOH/Tab use. Denies sexual activity. Pt was on class trip to Perth from her schoo! in Bunbury when she developed per-umbilical pain and anorexia, beginning on 40.9.2005. Initial pain followed by nausea ca 6 hours later. The pain then migrated to the RLQ with a maximum over MeBurney's point. «Labs showed leucocytosis with left deviation, Hb of 13.1, Het 41%, B-HCG was negative. «The patient was immediately given ampicilinigentamicin Nv. «AUIS was carried out, which displayed free fluid in the intra-abdominal space, « Astanding AXR was also performed which showed free air in the hepaticophrenic recess. + Anemergent laparotomy was performed. A perforation of the severely inflamed appendix observed, along with intraperitoneal abscess formation. * Appendectomy performed; abscess drained.* Pttransferred to SICU. Fever subsided. Transferred to a normal room. © Ciprofioxacin iv on Post op Day 1 + 3 days. Discharge plan: Pt is ready to be discharged to rehab centre. She should re-present to this clinic on 1.10.05 for general assesement. Contact Dr. Brown if fever >38°C, signs of infection or inflammation, SBP < 100 or >160 mmHg. WRITING TASK: You are transferring Miss Susan Surandan to the Bunbury General Rebabilitation Ceatre, Write a discharge summary to accompany the patient. In your answer: ‘¢ Expand the relevant case notes into full sentences. Do not use note form in the letter. © Use correct letter format. © The body of the letter should be 180 - 200 words Tong,Bunbury Rehabilitation Centre Bunbury 18/09/05 Dear Sir/Madam, Re: Miss Susan Sarandon 15 years old 1am writing to refer to you Susan Serandon, a 15 year old 10 grade student, who is an only child. she had an adenoidectomy in 1997 and is on medication for ADHD. At present, she is recovering from an eppendizectomy. Susan presented to the Emergency Department of the hospital on 13/09/05 with signs of Peritonitis and septic shock and a temperature of 39 degrees Centigrade. This wes three days after Investigations showed leucocytes with left deviation, free fluid in the abdominal space and fice air in the intraperitoneal recess. An emergent leporotomy revealed a severely inflamed, perforated appendix, with an intraperitoneal abscess. An appendicectomy was performed and the abscess was drained. The patient is now in a normal room as her fever has subsided, ‘Ciprofloxacin was administered on day's ane to three post operation ‘Susan is ready for discharge to your centre. Please could you ensure that she re-presents to this clinic for a general review, Ifthe paticnt’s temperature exceeds 38 degrees, or if there are any signs of infection or inflammation, please contact Dr Brown. Should you require any further information ahout Susan, please do not hesitate to contact me. ‘Yours sincerely, (Ms) Jenny Marshall