CASE NOTE 18

You are Shelly Kate charge nurse in Blue well Hospital

Patient Name: Maria John

Age: 60 Years
Address: 201/275 Alfred St.North Sydney NSW 2060

Admission: 11/12/2014
Discharge 14/12/2014

Social back ground

Married, Lives with husband, rental flat, 2 children working in abroad /visit home rarely.
Husband chronic smoker use 30 cigarettes per day.
Mother has DM .

Medically History
 Osteoporosis 2011
 Irritable bowel syndrome
 Hypertension & Stroke [RT side Paralysis]
 Hyperthyroidism since 6 month c/o increased fatigue, weight loss, hair loss Insomnia, sweating,
irritability [may 2014]
 Osteoarthritis
 Seizure disorder
 Hernia repair2010

Reason for admission

 Joint pain, abdominal pain, constipation

 Irritability, dry mouth
 Slurred speech
 Dizziness
 Fatigue
 Increased thirst

Vital signs

 Blood pressure 170/110mm of hg, PR: 92/mt, RR: 18mt, Temp: 98.6degree f
Lab investigation

 Decreased TSH, increased T3 T4

 Hemoglobin- 8
 Blood sugar value showed more than 400.
 MRI: slight bleeding temporal lobe
 Ultrasound sonography : slight bulging in RT upper quadrant of the abdomen.
 X-ray – neck – enlarged glands.

Treatment

 Ramiprill 5mg daily

 Thyroxin 25mg twice daily
 Inj – insulin
 Calcium supplements
 NSAIDS
 Paracetamol 500mg twice a day
 Pantaprazole 40 mg once a day
 A whole blood transfusion done in operative period in 2010

Discharge Plan

 Recommended Thyroidectomy, patient requested medical management

 Continue on going medication
 Physiotherapy
 Dietary modification
 Advised regular exercise
 Fiber containing diet and salt restricted diet.
 Monitor walking after each meal
 Include calcium supplement
 Limit dairy products
 Review with TSH report after 2 weeks.

Task

You are a charge Nurse of Maria John, write a letter to Dr. Patric Dsouza, senior endocrinologist, Blue
well hospital Australia,468 St Kilda Rd, Melbourne, VIC 3004. For further assessment and treatment.