Ms Angele Coyne
Surgical Ward A
Newtown Public Hospital
16 June 2018
RE: Kenneth Mason, DOB : 27 February 2000
I am writing with regard to Mr Kenneth Mason, who has been recuperating from chest pneumothorax. He requires ongoing care and monitoring after being transferred to your ward.
Today, Mr Mason presented with the complaints of breathing difficulty and chest pain which is increasing while coughing. As a result, he has been diagnosed with chest pneumothorax revealed by chest X-ray. On assessment, oxygen saturation 92%,nasal flaring and restlessness have been noticed. Although he was oriented, had slurred speech . In addition, he had discoloration of skin and mucous membrane along with this, he found to have air entry upon his right lung .
Mr Mason is a secondary student of Perth university and a varsity football player. He has had a right femour fracture in January 2018 and concussion in March 2015 after being hit with a ball accidently.
As a part of immediate management, The ICC insertion has been performed and connected to water sealed drainage. In addition, morphine 10 mg IV stat given and administered 2 litres of IV fluids over 24 hours . Upon transfer, it would be greatly appreciated if you could monitor his vital signs until it becomes stable and check for any bleeding in ICC .Based on his current condition, he allowed to have free fluids and light meals . A nurse will accompany him to report his current situation ,treatment and further care.
Thankyou for taking care over Mr Mason, should you have further queries can clarify with the accompanied nurse.