QQ 1135. Ms. Sandra Peterson - Letter - Bushra Tabassum
- GrandMasterClass
- Aug 4, 2021
- 1 min read
The community nurse
Spirit community Health Centre
Cnr bell and burn Streets
Applethrope
NSW,2171
22 March 2012
Dear Nurse
Re: Ms Sandra Peterson,DOB: 09 January 1921
I am referring Ms Sandra, who was diagnosed with upper respiration tract infection into your care for further management of medication compliance and ongoing support.
On 13 th March, Ms Sandra initially compliant of a productive cough. Subsequently, decreased mobility, increased confusion along with breathlessness, dizziness and three incidents of fall were reported. Consequently, had an emergency admission on 20 March.
An x-ray,a CT scan were ordered which was unremarkable. A full blood count test was conducted which showed white cell count and haemoglobin to be 9.0 and 115 gl respectively. Normal saline was administered for a day. Augmentin 500mg for twice a day was commenced.
Currently, she is hemodynamically stable. Breathing problem are now resolved and now maintaining saturation on room air. Although ambulation for short distance is possible with the seat walker,a wheelchair and assistance is required for long distance.
Medical history is remarkable for hypertension dementia and occasional urinary incontinence.
Based on the above mentioned circumstances, regular monitoring of medication compliance is recommended along with educating the daughter regarding polypharmacy and assistance with activities of daily living is required.
A rationalised medication chart have been attached for your persual. In case you require any additional information please do not hesitate to contact me.
Yours faithfully
Charge Nurse
Medical assessment unit
Spirit hospital.
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