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    Case Notes 5: Patient Details

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    BINCY
    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.

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    Case Notes 5: Patient Details

    Uploaded by

    BINCY
    677 views2 pages
    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.

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    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.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    677 views2 pages

    Case Notes 5: Patient Details

    Uploaded by

    BINCY
    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.

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    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.

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