(Identification: Ms. Rebecca Moskowitz is a 79-year-old, Jewish lady who lives alone.
Situation: Ms. Moskowitz presented to the emergency department at 8:00 a.m, this morning after a fall on the stairs in her two-storey home at 6:30 am this morning. X-Ray of the right-sided elbow has revealed an Olecranon fracture. She has also sustained a small wound on her left elbow. She vomited once after having a sandwich around 11:00 a.m. Since then, she has refused to eat or drink anything. She has been transferred to the medical ward for a 48-hour observation. Ms. Moskowitz’s right arm has been placed in a back slab cast for 2 weeks.
Background Ms. Moskowitz’s past medical history includes the following:
• Unstable diabetes mellitus which was diagnosed at the age of 35 (Metformin 500mg / BDS).
• Diagnosed with osteoporosis last year (Fosamax 35 mg. orally once a week).
• Hypertension (Ramipril 5mg / ODS).
• Past Surgery of a Hysterectomy for Uterine fibroid at the age of 30 post-pregnancy.
Personal, social and family background:
• Lives alone in her own two-storey house, independent with all ADLs. Has a cleaner come in once per week. Her 52-year-old son and his family live nearby. They are very supportive of her.
• Is retired. No financial stress.
• Reports many social friends. Alcohol intake is the occasional sherry at night.
• History of smoking (10-12 cigarettes per day); however, quit smoking since she was diagnosed with Osteoporosis.
• Poor diet quality, as she does not like to cook for ‘just herself’. Prefers ready-to-cook meals.
Assessment: On examination, you note that the patient has a temperature 38 0 C, BP - 155/ 88, RR-18/min, and
Pulse is 86/min. She is having 6/10 pain in her right elbow. O 2 saturation 100% on room air. Ms. Moskowitz is 156cm and her weight is 82 kg.
Recommendation: 1 hourly observation for the next 12 hours including neurological observations. Regular pain assessment. Encourage food and fluid intake. Monitor for any dizziness, headache or nausea, or vomiting.
Complete the admission record based on the case scenario for Ms. Rebecca Moskowitz. Ensure that all sections are completed and meet the legal requirements for documentatio
