In Context Case Summaries Profile of Adult Patient Cases pages 2-37

Profile of Adult Patient Case 00-009

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Profile of Adult Patient Case 00-009

Document summary

Patient admitted as an acute emergency admission with Increasing SOB for 2 weeks.

Now finding it difficult to get around house; Cough; No sputum SOB at rest; PND a; Orthopnoea a; Ankle swelling for last 7 days, diagnosis Left Ventricular Heart Failure (LVF)

Treated with diuretics and Digoxin.

Profile of Adult Patient Case 00-012

Document summary

This lady was admitted as a planned admission into hospital for a left Hemicolectomy and reversal of a colostomy.

Her previous medical history included a colostomy one year prior to the procedure, which she sustained a Deep Vein Thrombosis (DVT) post operatively. She is also known to have a respiratory condition although it is unclear as to whether this is Asthma or Chronic Obstructive Pulmonary Disease (COPD). She is also known to have arthritis to her right shoulder.

This lady remained in hospital for a period of twelve days, the procedure was performed and she made a successful recovery, an Out Patients appointment was arranged for four weeks later.

Profile of Adult Patient Case 00-013

Document summary

Acute admission via doctors deputising service with history of Right Upper Quadrant and epigastric pain associated with vomiting.

History of previous surgery for Intussusceptions as a child and bowel resection fifteen years ago. Examinations, including ultrasound were unremarkable. Managed conservatively with Intravenous Infusion and sips of clear fluids plus analgesia.

Patient made a spontaneous recovery and was discharged on day three. At follow up she was asymptomatic and discharged ROD.

Profile of Adult Patient Case 00-014

Document summary

Acute admission with intermittent severe abdominal pain associated with nausea and vomiting.

Previous extended right hemicolectomy and splenectomy; partial pancreatectomy. For Dukes B colonic adenocarcinoma. Treated conservatively nil by mouth and intravenous infusion.

CT scan reported a Inflammatory mass, antereomedial abscess, left psoas.

Pain settled down quickly and was she was discharged home on day three.

Profile of Adult Patient Case 00-015

Document summary

Acute admission with history of severe upper abdominal pain associated with nausea and vomiting. Already scheduled for waiting list laparoscopic Cholecystectomy in three days time.

Settles quickly on conservative management, Nil by Mouth, Intravenous Infusion and proceeds to surgery as planned.

Uneventful Post-operative recovery and discharged on day seven with follow up in six weeks.

Note from transcriber. Nursing notes not available.

Profile of Adult Patient Case 00-017

Document summary

List case admission for repair anterior posterior vaginal repair.

Surgery performed repair of Cystocoele + Rectocele. Made a relatively good post – operative recovery complicated by problems passing urine when the catheter was removed. Residual urine determined by ultrasound scan measured 839 ml confirmed as 900ml at re-catheterisation. Patient was ‘desperate’ to be discharged with or without the catheter and it was agreed to discharge with catheter in situ to return in one week for further trial without catheter.

Profile of Adult Patient Case 00-018

Document summary

List case admission for vaginal hysterectomy because of irregular menses, pain and dyspareunia; young at thirty nine for this procedure.

Surgery performed Vaginal Hysterectomy with pelvic floor repair. Large uterus but no operative complications. Post operatively complained of pain in both right and left iliac fossa and periumbilical. Developed a low grade pyrexia the aetiology of which was never fully explained, treated with Augmentin.
Catheterised for the operative procedure catheter removed on day six only twenty five ml of residual urine measured on post micturition scan. Urine noted to have blood ++ protein ++ Mid Stream Urine specimen (MSU) sent to lab for culture and sensitivity (C&S).

Discharged on day seven to continue antibiotics.

Profile of Adult Patient Case 00-019

Document summary

Thirty-nine year lady admitted for total abdominal hysterectomy because of menorrhagia and uterine fibroid.

Uneventful intra - operative period. Developed severe abdominal pain post parandial on post operative day three queried to be paralytic ileus or obstruction. Settled down on nil by mouth and IV fluids. Catheter removed on day four scan showed 250 ml residual urine but no intervention ordered. Discharged on day seven.

Profile of Adult Patient Case 00-020

Document summary

List case admission for vaginal posterior repair for prolapse. At time of operation large rectocele identified, no enterocele, small cystocele.

Constipated post-operatively treated with oral laxatives, suppositories and enemata (phosphate, Microlax). Catheterised for the operative procedure removed on day four but catheter had to be reinserted because of urinary retention. Catheter removed on day six with no evidence of urinary retention on ultrasound scan (25 ml residual).

Discharged on day eight; returned to the ward on day ten complaining of vaginal and perineal pain reassured and prescribed Sultrin cream. Swab taken for Culture & Sensitivity was reported as showing no significant growth.

Profile of Adult Patient Case 00-021

Document summary

This sixty five year old lady was admitted into hospital with abdominal pains. It is documented that her history is quite vague. She has a medical history of Chronic Obstructive Pulmonary Disease (COPD), Schizophrenia and Hypertension. She has also had surgery in the past for a Peptic Ulcer and she has recently been treated for a chest infection.

There are comments made within the medical notes that it is difficult to obtain information from her regarding her symptoms and she is described as a ‘vague historian’. However following a medical assessment, she is diagnosed and treated for constipation with enemas which apparently relieve the constipation. She is discharged home following a five day stay in hospital.

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