Name: Miss Cassandra Kinser

Miss Cassandra Kinser, a 32-year-old, is a patient in the medical ward in which you work.

Patient Details:
o Name – Miss Cassandra Kinser
o Marital Status – Single
o Next of Kin – Unknown
o Residence – Cabramatta
o Date of Admission – January 17, 2018
o Discharge Date – January 17, 2018
Admission Diagnosis
o Lip laceration (alleged assault by boyfriend/not seek medical care)
o Abdominal pain
o Burning with urination last several days
o May have STD
o Denies vomiting/diarrhea
o Sexually active, does not use protection
Social Background
o Smoker (chain)
o Alcoholism
o Denies illicit drugs
o Past medical history: History of Schizophrenia

Diagnosis
o Infected lip laceration
o Urinary tract infection (UTI)

Medical progress
Constitutional:
o Denies fever, chills, dizziness, weakness
Cardiovascular:
o Denies chest pain/palpitations
Respiratory
o Denies shortness of breath/cough
o All other review of systems – negative
Nursing Management
o For lip: Cipro 500 mg orally twice daily x 6 days
o Clindamycin 300 mg orally 4 x daily x 10 days
o Peridex mouthwash 10 mL swish and spit after meals and before bed
o Oxycodone one orally every 4 hours.
 o UTI: follow up with GP Postoperatively monitor critical

Assessment
o Discharged home – Good condition
Discharge Plan
o Appointment made at sexual health clinic.
o GP to follow up results, monitor antibiotics, treat for UTI.

Task:
Using the information given in the case notes, write a referral letter to Miss Kinser’ General
Practitioner, Dr Travis Wrenn, at Punt Road Medical Clinic, 172 Punt Road, Mosman, 2088, for further
medical evaluation and treatment.