CASE NOTES:

Mr George Chien, a 54-year-old, is a patient in the medical ward in which you work.

Hospital:

St. Andrews Hospital, 280 Pechey Street, Templestowe

Patient details

Name:
George Chien (Mr)

Marital status:
Married

Residence:
Templestowe

Next of kin:
Thomas (26, single, lives in Taiwan) Susan (22, single, lives at home, student)

Admission date:
10 January, 2018

Discharge date:
12 January, 2018

Social background:
Accountant
Moderate social drinker
Non-smoker
Enjoys watching soccer, walking dog

Medical background:
Osteoarthritis
Right knee: progressive, severe pain - TKR (27.12.17)
Severe difficulty w. mobility (right lower extremity)
Glandular fever (2014)
History of shingles

Admission diagnosis:
Post right total knee surgery
Impaired mobility and self-care activities
Postoperative anemia
Right knee, moderate swelling - fluid.

Medical progress:
Moderate anemia
Discomfort of skin on his back
Moderate swelling knee - ice pack treatment
Incision well healed, clean, dry.
Arixtra prescribed during hospitalisation, discontinued just prior to discharge.

Nursing management:
Supervised level for bed mobility / modified independent level for transfers.
Can ambulate < 100 meters with front-wheel walker
Limited range of motion of knee
Patient at supervised level for eating, grooming, bathing
Minimal assistance level for lower body dressing
Eager to go home
Prescription painkillers and thyroid support 60 mg daily and multiple supplements

Assessment:
Medically stable

Discharge plan:
Patient discharged home w. family assistance.
Regular diet as tolerated
Needs acute, comprehensive rehabilitation
Patient has front-wheel walker

WRITING TASK:

Using the information given in the case notes, write a referral letter to Ms Loretta
Pasquale, who is a physiotherapist at the Templestowe District Medical Clinic, 43
Anderson Street, Templestowe, regarding Mr Chien’s physiotherapy needs.

In your answer:

• Expand the relevant notes into complete sentences

• Do not use note form
• Use letter format

The body of the letter should be approximately 180 - 200 words.

MODEL LETTER:
12 January, 2018

Ms Loretta Pasquale
Physiotherapist
Templestowe District Medical Clinic
43 Anderson Street
Templestowe

Dear Ms Pasquale,

Re: Mr George Chien, 54 years old

Mr Chien recently underwent right total knee surgery resulting in his current limited mobility. I
am writing to refer him into your care for rehabilitation.

An osteoarthritis sufferer, Mr Chien was admitted to St Andrews Hospital two days ago suffering
severe pain and fluid build-up in his right knee, a result of the previous knee operation.
Consequently, both his mobility and self-care activities were severely limited.

During hospitalisation here, the incision site on his knee was successfully treated with ice packs
and it healed well. His mobility was supervised and he was given the use of a front-wheel walker
to assist in this.

Mr Chien still experiences limited motion in his right lower extremity and can walk only with his
front-wheel walker and less than 100 metres. However, he is now medically stable and ready for
discharge with assistance from his family, who will supervise his self-care activities.

Because Mr Chien continues to experience severe difficulty with mobility, he needs your
professional assistance for acute and comprehensive rehabilitation. Please note, the patient uses
his own front-wheel walker.

If you have any queries, please feel free to contact me.

Yours sincerely,

Nurse