Scribd
Upload
848 views2 pages

Case Notes 5: Patient Details

Catherine Edith is a 28-year old restaurant manager who is 10 weeks pregnant with her first child. She has a history of anxiety, depression, and weight loss due to a previous abortion. Her current pregnancy is considered high risk due to low hemoglobin levels, borderline hemoglobin A1C, and poor eating habits of skipping meals and preferring junk food. She requires dietary counseling, nutritional assessment, and psychological consultation to address her mental health and ensure a healthy pregnancy outcome.

Uploaded by

BINCY
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
848 views2 pages

Case Notes 5: Patient Details

Catherine Edith is a 28-year old restaurant manager who is 10 weeks pregnant with her first child. She has a history of anxiety, depression, and weight loss due to a previous abortion. Her current pregnancy is considered high risk due to low hemoglobin levels, borderline hemoglobin A1C, and poor eating habits of skipping meals and preferring junk food. She requires dietary counseling, nutritional assessment, and psychological consultation to address her mental health and ensure a healthy pregnancy outcome.

Uploaded by

BINCY
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 2

CASE NOTES 5

Read the case notes below and complete the writing task which follows: You are a
community nurse visiting the patient daily.

Patient Details
Name: Catherine Edith
Age: 28 yrs
Occupation: Restaurant manager
LMP: 15/07/2019
Current Doctor: Dr. Shaw (gynecologist)

Present History (01/10/19)


 1st trimester – 10th week
 Anxiety, depression due to previous abortion, weight loss
 Decreased food intake (Hb-9 mg/dl) hyperemesis
 HbA1C just below boarder line (6.5)
 Weight -45 kg (pre pregnancy-46 kg)
 Skip the meals very often, decreased fluid intake
 Food preference : junk food, likes to eat more baked food items
 Needs education on proper diet during pregnancy
 ? any nutritional deficiency disorder

Social History
 Next of kin: Husband (business)
 Elder sister baby- Down’s syndrome
 Lives in Sydney, Orange, Peanut garden, NSW 2001
 Rented house, two storey building
 Married 5 years
 Caring mother, limited friends, occasional drinker

Past History
 Abortion -1
 Infertility treatment – 3 yrs
 Appendectomy – 2005
 Flu vaccination 5 months back
 Migraine (Tab. Grenil 100 mg)
 Rt. Oophorectomy – 2016
Treatment Plan
 Patient urgently needs information on eating patterns, strong encouragement for
improving diet.
 Advice on reduce or eliminate drinks
 Counseling therapy (anxiety, depression )
 Requires advice from dietician
 Nutritional assessment
 Psychological consultation with husband and mom
 Need to be educated regarding diabetes and importance of diabetic diet

Writing Task

 Using the information in the case notes, write a letter to dietician, medical
center, Brisbane, NSW 4000.
 Using the information in the case notes, write a referral letter to Dr. Samuel
Philip, Psychologist. Finders Medical Centre, Bedford Park, 5042, Sydney.

You might also like

pFad - Phonifier reborn

Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.

Note: This service is not intended for secure transactions such as banking, social media, email, or purchasing. Use at your own risk. We assume no liability whatsoever for broken pages.


Alternative Proxies:

Alternative Proxy

pFad Proxy

pFad v3 Proxy

pFad v4 Proxy