Assignment - Task 3 Case Notes: Ling Wu

Read the case notes below and complete the writing task which follows.
Time Allowed Reading Time: 5 minutes Writing Time: 40 minutes
Today’s Date 22/02/14
Patient details:
Name: Ling Wu, female
DOB: 01/03/1996
Status: Single

Social History
Ling is a student of the Bachelor of Accounting course in the University of Western Sydney
Enjoys cycling
She lives in a 3-bedroom one-story house with her parents and younger sister
No tobacco, alcohol or drug use

Past Medical History: None

Allergies: no known allergies
Date of admission: 26/01/14 –Trauma Ward at St. Angus Public Hospital
Date of discharge: 23/02/14
Diagnoses
Left tibial-fibular fracture secondary to cycle accident
Left above-knee amputation
Phantom limb pain

Description of accident: The patient was parked off the road, when a car skidded across and
collided with her cycle.
At Emergency Department
The initial assessment: an open tibial-fibular fracture of the left extremity with near amputation
Her Glasgow Coma Scale was 15 & head CT was negative
Obs: BP- 178/90 mmHg, P-110bpm, RR- 22/min, SpO2 – 90 in room air
The patient was taken to the operation theatre and above-knee amputation was performed on the
same day

Hospital progression
27/01/14
Post – operative pain controlled with intravenous opioids (morphine) via PCA infusion pump
The limb has been elevated for one or two hours, two or three times each day to reduce local
oedema & pain
She had been totally assisted with mobility
Bladder care (Indwelling catheter inserted on 26/01/14 and removed on 28/01/14)
Deep venous thrombosis (DVT) prophylaxis: The patient had negative Dopplers and prophylaxed
with Fragmin 5000 IU once daily, subcutaneously.
Bowel management: The patient was started on Citrucel secondary to her pain being treated with
narcotics. On a high fibre diet and fluid intake
Prevention of infection: Cephalexin IV tds - 5/7, protective dressing and drainage.

01/02/14
She complained of a cramping and twisted posture of the missing limb (phantom limb pain), treated
with opioids (Endone 5 mg BD), tricyclic antidepressant (amitriptyline 10 mg tds)and antiepileptic
(Neurontin 100 mg tds)

Commenced participating in physiotherapy program and involved with pre-prosthetic training.

15/02/14
Orthopaedics
Amputation incision remained intact,
Stitches out
Wound almost healed
Residual limb wrapped with an ace bandage to ↓swelling and pain and re-applied every 3-4 hours
Mental state: insomnia, silent rumination, and social withdrawal
She has a fear of being seen in public
Consulted with a Social Worker
22/02/14
Fragmin was discontinued. No signs of DVT were observed
Phantom limb pain: she remained stable on Paracetamol-Osteo 665 mg qid and Tramadol prn
Min oedema of the stump w/peeling skin, no signs of infection
Bowel management: Citrucel was discontinued. She started Coloxil with Senna one tablet bd and
Dulcolax suppository prn
Fluids, Electrolytes, Nutrition: The patient was on a regular diet
Able to walk with rolling walker for short distances along the ward and use wheelchair for long
distances, but needs ↑ assistance for stairs
Trained to wrap the stump with ace bandage
Parents were educated about assistance with ADL
Vital signs with no abnormalities

Discharge plan:
Warm compresses, ice packs and massage are recommended for phantom limb pain
To continue regular exercises as per physio program and dressings with ace bandage to shape the
amputated limb for fitting with a prosthesis
The patient is at increased risk of developing post-traumatic stress disorder (PTSD) or depression
in the late period after the trauma. Peer counselling or support groups to support her can be helpful
The patient will be seen at the trauma clinic at 3:30 p.m. on 13/04/14

Medication at discharge (self-administration):

Neurontin 100 mg q8 h
Paracetamol Osteo 665 mg q8 h, prn
trazodone 50 mg p.o. at bedtime prn
Laxatives prn

Writing Task
You are a Charge Nurse at the trauma ward of St Agnus Hospital, Sydney. Using the information in the
case notes, write a letter to a Community Nurse at Spirit Family Medical Practice, 12 Gar Street, Holy
Hill, NSW, 2167. In your letter explain relevant social and medical histories and request the
Community Nurse to visit Ms Ling Wu after discharge to provide proper health management and
assistance for this patient and her family.
In your answer:
Expand the relevant case notes into complete sentences
Do not use note form
The body of the letter should be approximately 180~200 words
Use correct letter format