You are a Alice Murphy, a qualified nursing sister working in

Emergency department, Price Charles General Hospital. Address is

Case Notes 10 Downing Street, London, SW1A 2AA. Contact Ph. 400 3897 7642.
The patient had arrived from an ambulance for the 2nd time due to
breathing difficulties
Patient details
Name Charles Kane Dothraki
Age 45 years old
Date of Birth August 09, 1963
Date of admission June 13, 2018
Discharge Date June 16 2018
 Father – suffers from Tuberculosis
o Died last March
 Mother – hypertensive
 Patient is on Amlodipine 25mg mane
Social History  Patient’s BP: 160/95 mmHg
 Living in a nuclear family type
 Has Tuberculosis since 2017
 Has been stabbed near the chest area after a hold-up incident
 Abnormal vital signs before discharged
13th of June 2018
 Had fluid accumulation in pericardial sac
 Was aspirated and resumes a normal cardiac rhythm
 (Pericardiocentesis) Aspiration done but refuses to be further
treated in the hospital
 Wanted to go home
 Verbalizes anxiety
 In Pain- given pain killers for relief as needed
 Abnormal ECG results
 Abnormal heart beats
 Presented with difficulty of breathing until stable
Medical history
16th of June 2018
 Signed a DAMA
 Discharged with no known definitive progress
 Accompanied by sister upon discharge
 V/s: BP: 130/90
 PR: 86
 RR: 22
25th of June 2018
 Rushed into ER due to difficulty of breathing
 RR: 30 shallow and grimacing
 HR: 110
  Cannot speak
 Hands holding chest areas
 Muffled heart sounds on auscultation
 Jugular vein distention
 Pallor or cyanosis
 Pulsus paradoxus
 Restlessness
 Chest X-ray shows slightly cardiomegaly
Diagnostic test
 Echocardiography records pericardial effusion with signs of
results
right ventricular and atrial compression
 For close monitoring of ECG changes, blood pressure, pulse
rate, level of consciousness, and urine output to detect signs of
decreased cardiac output
 For emergency aspiration
Plan  Explain the procedure to the client’s sister
 Postoperatively monitor critical parameters, such as vital signs
and ABG levels, and assess and breath sounds.
 Give pain medication as needed
 Be alert for complications, such as hemorrhage and arrhythmias

Writing task #1
Using the information in the case notes, write a letter to Dr. Alfredo Cordova Senior for
admission of the patient and emergency surgery.
 Expand the relevant notes into complete sentences
 Do not use note form
In your answer  Use letter format
 The body of the letter should be approximately 180 – 200
words.