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Original Question

Write a progress notes entry regarding Ms Warral once she has returned to your ward following her surgery (review the post-operative information to assist). Patient History: Name: Ms. Sue Warral Age: 50 Ethnicity: Aboriginal Torres Strait Islander Languages Spoken: Aboriginal English and English Marital Status: Divorced from children’s father. Currently in a defacto relationship with James Michaels (55) Medical History: Chronic asthma, hypertension, hiatus hernia, osteoarthritis knee’s, smokes – 1 pack per week, alcohol – social Weight 95kg, height 160cm, BMI 37 Previous history of deep venous thrombosis Occupation: Part-time reception duties at local primary school Next of Kin: James Michaels defacto husband Dependents: 2 children (Rebecca 12yrs & Nathan 10yrs) Family: Children visit their father every other weekend. Sue’s mum and a sister live nearby. The whole family gets together on a regular basis. Interests: Socialising, gardening, reading Ms. Sue Warral presents in your gynaecological surgical unit for an abdominal hysterectomy tomorrow. Ms. Warral has had three consecutive abnormal PAP smears in the past four months. The patient states she has noticed an unusual vaginal discharge over the past six months. On further investigation Sue was found to have stage II carcinoma of the cervix. She reveals to you she is anxious about the cancer and having young children to look after. She also confides that she is worried that her partner will still love her. Sue’s surgeon Dr Turner stated that they would decide what further treatment will be required after the pathology findings of the surgery. On admission to your ward, the day of surgery, you take Ms. Warral vital signs. BP 155/85 Pulse 88 bpm Temperature 36.6 Respirations 18 Weight 95kgs SpO2 97% Allergic to penicillin The patient gives you a list of her current medications. Salbutamol 1-2 puffs every 3 hours as needed Metoprolol – 50mgs daily am Thyroxine – 50mcgs daily am Omeprazole 20mg daily am Panadol Osteo – two tablets TDS

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