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


Profile of Adult Patient Case 01-065



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Profile of Adult Patient Case 01-065


Case summary

This twenty-one year old gentleman was admitted to the Ear Nose and Throat Department via the Accident and Emergency Department with Tonsillitis.

This patient had no previous medical history and was not taking any medication.

Following admission into hospital he was treated with analgesia and Intravenous antibiotics, which appeared to improve the condition. He was discharged home after a five-day stay in hospital. An Out Patient appointment was arranged for three months time.



Profile of Adult Patient Case 01-066



Case summary

This sixty-three year old gentleman was admitted to the Ear Nose and Throat (ENT) ward as an elective admission for a dissection and biopsy of a malignant tumour to his neck. He had attended for a pre- operative assessment one week prior to admission.

His previous medical history was complex and included Ischaemic Heart Disease (IHD), Coronary Artery Bypass Graft (CABG), Myocardial Infarctions, Anaemia, Partial Gastrectomy and Osteoarthritis. He also had been diagnosed with squamous cell carcinoma of the vocal cord one year earlier, which was excised and treated.

The procedure was undertaken and the tumour removed and sent for histology. Post operatively he was transferred to a High Dependency Unit and was transferred back to the ward two days later. He was discharged home following a seven-day stay in hospital. A follow up appointment was arranged for him to attend the Out Patients clinic.


Profile of Adult Patient Case 01-069


Case summary

This seventy-six year old lady was an elective admission to the ophthalmic ward to be treated for retinal detachment and removal of cataract to the right eye.

Her previous medical history includes Angina, Ischaemic Heart Disease (IHD), Appendecectomy, Cystoscopy and a Colostomy following surgery for Cancer of the Rectum.

There is evidence within the Multi disciplinary notes that despite a detailed previous medical history the patient was not ‘clerked in’ by the doctor prior to surgery and was therefore not prescribed her routine medication. However, the surgical procedure was performed under a general anaesthetic and following an uneventful recovery period in hospital, the lady was discharged home after a five-day stay in hospital.

Profile of Adult Patient Case 01-070



Case summary

This sixty-six year old gentleman was admitted via the Ear Nose and Throat (ENT) department with a stridor. One month prior to this admission he had a partial left Laryngectomy for carcinoma of the larynx.

His previous medical history consists of a myocardial infarction twenty-three years ago and Ischaemic Heart Disease (IHD).

On the day of admission he was taken to theatre for a laryngoscopy and possible tracheotomy. He returned to the ward following debridement of tissue in the larynx, samples of tissue were sent to the Pathology laboratory for histology. Following the operation, his breathing improved and he was discharged home following a three-day stay in hospital. An Out Patient appointment was arranged for the following week.

There is evidence that the pathology report of the sample of tissue taken in theatre revealed carcinoma, however there is no evidence to suggest that the results were available before the patient was discharged. It is therefore assumed that the patient would receive the results when he attended the Out-Patients appointment one week following discharge from hospital.

Profile of Profile of Adult Patient Case 01-071


Case summary

This seventy-nine year old lady was referred to the Consultant Ophthalmologist from Consultant Dermatologist for reconstruction surgery of the face, following recent surgery for removal of extensive cell carcinoma to the face.

There is no record of previous medical history apart from carcinoma of the face, although she is on medication.

A reconstruction of the right medial canthus was performed by using the forehead and cheek flap under a general anaesthetic. She was discharged home following a five-day stay in hospital. An Out Patient appointment was arranged for her to attend the ophthalmic clinic for the removal of sutures.

Profile of Profile of Adult Patient Case 01-072



Case summary

This seventy-five year old lady was admitted as an elective admission to the Eye ward for a corneal graft, cataract surgery and occlusion of tear passages under a General Anaesthetic.

Her previous medical history consisted of Rheumatoid Arthritis, Glaucoma and a Total Hip Replacement.

The procedure was performed and the lady was discharged home following an eight-day period of stay in hospital. An Out Patient appointment was arranged for the following week.


Profile of Profile of Adult Patient Case 01-073



Case summary

This forty-one year old lady was admitted to the Ear Nose and Throat unit with two day history of pain and swelling to the right side of her face and mouth. She was experiencing problems breathing and was only able to swallow fluids.

She was referred to the Maxillo Facial department and diagnosed with a tooth infection. She was treated with Intravenous antibiotics and analgesia and the swelling reduced. Following a four-day stay in hospital she was discharged home. An Out Patients appointment was arranged for her to attend for a tooth extraction.

Profile of Profile of Adult Patient Case 01-074


Case summary

This eighty-seven year old lady was admitted into hospital via the Accident and Emergency (A&E) Department with abdominal pain and chest pains which she had experienced for a period of approximately three days. Her previous medical history includes Parkinson’s disease, Hypertension and Glaucoma.

Following various investigations, she was diagnosed with constipation, for which she was treated with medication. The nursing management for this lady includes referrals to the Occupational Therapy, Physiotherapy and Social Work department.

Throughout her period of stay in hospital there is evidence of discussions between the nurses and the patient’s son that he intends to buy a house and live with his mother and become her carer. However, it was decided that in the meantime she needed further support in her own home following her discharge.

The patient’s condition improves following treatment in hospital and she was discharged home following a twelve-day stay.



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