CASE NOTE 6

You are a charge nurse in Royal Perth Hospital, UK.

Patient Details
Name: Angelena Jolly
Age: 55 years old

 Married lives with husband [taxi driver] and 2children

 Occupation: Computer Engineer
 Hobbies: watching cinema, social parties
 Admission Date: 16/02/19
 Discharge date: 20/02/19
 Diagnosis: hemorrhagic Tonsillitis, Rheumatoid Arthritis

Medical History
 DM- Diagnosed in 1999[insulin dependent] self administration of insulin
 Hyperlipidemia
 Hypothyroidism – on treatment with levotheyroxin 50mg daily

Hospital details

 Severe joint pain all over the body

 Extreme throat pain.
 Head ache, fever, weakness, dysphagia, cough without expectoration
 Mild breathing difficulty due to chest congestion
 Decreased appetite, constipation

Social History

 HusbandMr. Alexander- retired pilot, known case of CKD (on dialysis for 5 years), DM and
hypertension
 Mother had thyroid dysfunction, Died due to MI.

Habits:

 Chain smoker, occasional alcoholism and consumes junk foods.

Vital signs

 Temp: 101.6degree f
 Pulse 102b/m
 Respiration -20b/m
 BP 153/98mmHg
Clinical Examination

 BMI-35 kg/m3
 Enlarged –Tonsils, red eyes, coated tongue
 Subj.data; patient reported bloody taste while swallowing saliva

Lab reports

 Significant increase in ASO titer, WBC and ESR

Treatment

 Antibiotic treatment –Amoxilin 1.2gm IV, TDS

 Fluid replacement Therapy
 Inj – Paracetamol 1 gm IV, three times a day
 Betadine gargling

Medical Progress

 Recovery not satisfactory

 Pain relieved
 Dysphagia remains
 Advised tonsillectomy. But patient requested surgery from Blue Well Hospital after 1 week.
 Advised exercises
 Dietary management
 Patient requested nursing home for 4 days post operatively as her husband goes abroad

Discharge Plan

 Referral to general surgeon

 Continue medication
 Inform if heavy bleeding occurs
 Advised admission after 3 days
 Continue gargling
 Rehabilitation for smoking
Task

1. Using the information given write a letter to Dr. Peter Frederick generl surgeon, Blue Well Hospital for
further treatment of the patient.

2. Using the case note write a referral letter to Ms. Anette Dsouza, Senior nurse, good well homecare,
Australia -310. Who will be responsible for Angeleenas’s continued care, after the operatio