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Case Notes & Analysis 3

This case notes will be used for writing today’s letters for correction. Before you proceed to writing this letter on the writing page, please read this case notes and answer the questions that below:

OCCUPATIONAL ENGLISH TEST

WRITING SUB-TEST: Nursing
TIME ALLOWED: READING TIME: 5 MINUTES | WRITING TIME: 40 MINUTES

Read the case notes below and complete the writing task which follows.

NOTES

Today’s Date 09/09/09

You are Simmy Joseph, a registered nurse in the Coronary Care Unit, St Andrews Hospital Brisbane. Felix Seastine is a patient in your care.

Patient Details

  • Name: Felix Seastine
  • DOB 12 January 1956
  • Address 9476 Old Dam Road, Blessham Q4390
  • Next of Kin Brother, Invictus Seastine, 72 Burke St, New Liverpool Q4490
  • Admitted 2 September 2009
  • Diagnosis: Obstructive coronary artery disease
  • Operation: Coronary artery bypass grafts (x 4) on 4th September.

Social History

  • Never married
  • Lives alone in own home just outside Blessham
  • Online business – home delivery – helped by brother and his three daughters
  • Currently out of business due to lock-down and red alert in Blessham.
  • Likes reading travel journals.

Medical History

  • Smokes 20 cigarettes/day
  • Alcohol: 2 x 300 ml bottles beer / day
  • Ht 170 cm Wt 99 kg
  • Usual diet: Sausages, deep fried chips, eggs, burgers, KFC and occasionally rice pudding.
  • Allergic reaction to nuts and oily food
  • Warty face due to excess acne; depressed about it.
  • Excess Testosterone; tried hormone reduction medication
  • Uses face-creams and washes face over 50 times a day (he has OCD?)

Nursing Management and Progress

  • Routine post-operative recovery
  • Advised to cease smoking, reduce alcohol (he says he cannot)
  • On low fat diet (resists and demands food high in fat)
  • Walks well
  • Wounds healing well
  • Routine visit from Social Worker

Discharge Plan

  • Returning home to Blessham today.
  • Appointment made for follow up visit to local GP Dr. Cinderella Austin, 2 pm 15/9/09
  • Local physiotherapist to continue rehabilitation exercise program.

Writing Task

Mr Seastine has requested advice on low fat dietary guidelines and healthy simple recipes along with “more practical advice” on managing acne on face. Write a letter to the Community Information Section of the Wells Foundation, Wimbledon Avenue, Brisbane on the patient’s behalf. Use the relevant case notes to explain Mr Seastine’s situation and the information he needs.

Include Medical History, BMI and lifestyle. Information should be sent to his home address.

In your answer:

  • Expand the relevant notes into complete sentences
  • Do not use note form
  • Use letter format
  • The body of the letter should be approximately 180–200 words.

Now, proceed to the questions below and see your score:

  • Question of

    Name of the patient?

    • Ms Felix Seastine
    • Mrs Felix Seastine
    • Mr Felix Seastine
  • Question of

    Admission details:

    • Admitted
    • Discharged
    • Being discharged
    • Will be discharged
    • At home
  • Question of

    What is the present condition of the patient?

    • Recovered
    • Recovering
    • Critical / Terminal
  • Question of

    What is the Purpose of the letter?

    • Home care
    • Advice /Information
    • Further treatment
    • Palliative care
  • Question of

    Who is the recipient?

    • Nurse
    • Carer
    • Others
  • Question of

    Is the patient known to the recipient?

    • Yes
    • No
    • Not sure
  • Question of

    What is the least relevant information in the case notes?

    • Social
    • Past Medical
    • Present Medical
    • Reading genre
    • No irrelevant information
  • Question of

    What is tricky?

    • Irrelevant information
    • Confusing dates
    • Confusing gender
    • None

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13 Comments

  1. 9 September, 2009

    The community information section
    Heart foundation
    Gregory Terrace
    Brisbane

    Dear sir/Madam,

    Re:Mr Bill O Riley
    Age:53years

    Mr O Riley is diagnosed with coronary artery disease and I am writing on behalf of him as, he would like to get information on low fat dietary guidelines and healthy simple recipes.

    Mr O Riley Body mass index is 31. He smokes in excess and consumes alcohol. In addition he consumes the high cholesterol diet such as sausage, deep fried chips, eggs.

    Mr O Riley was admitted to hospital and underwent coronary artery bypass graft. During his postoperative days he was provided with all routine care along with importance and measures to quit smoking, alcohol, low fat diet. Currently he has made a good progress, however requested the information.

    In view of the information kindly provide Mr O Riley the information in his address. Please note that he is allergic to nuts.

    Kindly do the needful at;9476 Old Dan Road, Goodwindi, Q4390 and please do not hesitate to contact me if you have any queries.

    Yours faithfully
    Registered Nurse
    Coronary care unit
    St Andrews Hospital
    Brisbane

  2. Community Information Section
    Wells Foundation
    Wimbledon Avenue
    Brisbane

    09/09/2009

    Re: Mr Felix Seastine v, 53 Years

    Dear Sir/Madam,

    I write this on behalf of Mr Seastine who has been under our care with obstructive coronary artery disease. He requires healthy and simple dietary recipes for his condition along with more practical recipes for acne on his face. He is being discharged today.

    Mr Seastine was admitted with the aforementioned diagnosis and has undergone coronary artery bypass grafting. He was advised to limit his smoking and alcohol consumption. However, he is reluctant. Currently, he has a good post operative recovery with a well healed wound. Although he was advised for low fat diets, he resists and demands for high fat diet. Apart from these, he is depressed about his warty face due to excess acne.

    Mr Seastine lives with a sedentary life style with high body mass index and he consumes alcohol and smokes in excess.

    In view of the above, it would be greatly appreciated if you could provide advice regarding healthy dietary regime for his current condition along with practical advice for acne management. Please continue his rehabilitation program by local physiotherapist. Kindly note that his follow up will be by his local GP Dr. Cindrella Austin on 12th of this month at 2pm. Of note, he is allergic to nuts and oily foods.

    Should you have further queries, please do not hesitate to contact me.

    Yours faithfully

    Simmy Joseph
    Registered Nurse

  3. Asha Aneesh.

    09 September,2009

    Wells Foundation
    Community Information Section
    Wimbledon Avenue
    Brisbane

    Dear Sir/Madam

    Re:Mr Felix Seastine,53 years

    Mr Felix Seastine has requested advice on low fat dietary guidelines and more practical advice on managing acne on his face.He is being discharged today.

    Mr Seastine underwent coronary artery bypass grafts five days ago and attained routine post operative recovery.He seemed to be depressed as he has warty face due to excess acne.He washes his face more than fifty times a day by using some face creams.He used hormone reduction medications to control excess testosterone.

    Mr Seastine is unmarried and works as an online business man.He drinks 600ml of beer and smokes 20 cigarettes in a day.He consumes deep fried chips,eggs,burger,KFC and sausages regularly.His weight is 99kg and height is 170cm.

    Mr Seastine is allergic to nuts and oily food.He demands food high in fat.He has been advised to stop smoking and control alcohol intake.

    Kindly provide information including simple recipes to manage his acne and send it to his home address.(9476,Old Dam Road,Blessham,043990)

    If you need further details, please do not hesitate to contact me.

    Yours faithfully,

    Simmy Joseph
    Registered Nurse

  4. 9 September,2009

    Wells Foundation
    Community Information center
    Wimbledon Avenue
    Brisbane

    Dear Sir/ Madam

    Re: Mr Felix Seastine
    DOB: 12 January,1952

    I am writing on behalf of Mr Seastine, who requires further advise on low fat dietary guidelines and helathy simple recepies along with the management of facial acne. He was diagnosed with obstructive coronary artery disease. He is being discharged today.

    Mr Seastine was admitted to hospital on 2nd of this month 2009. On investigation he was diagnosed with obstructive coronary artery disease for which he underwent coronary artery bypass graft surgery on 4th September,2009. His post operation recovery was uneventful. He has been commenced on low fat diet. He was advised to control his drinking and smoking habits but he is reclaunt.

    Mr Seastine lives alone in his own house .He is doing online business of home delivery services with the help of his brother and his daughters. He smokes 20 cigerattes and two 300 ml beer bottles in a day. He has a sedentary life style. His weight is 99 kilograms, height 170 cm. His Body mas index is 32.3.

    Mr Seastine also has acne on his face due to this he was depressed. For facial acne he has been using lots of facial creams. Along with this he also has Obesive compulsive disorder.

    It would be greatly appreciated if you could give required dietary guidelines to him. Worth to note please send details to his home address.

    If you have any queries, please do not hesitate to contact me.

    Yours Sincerely,
    Simmy Joseph
    Register Nurse
    Coronary Care Unit
    St Andrews Hospital
    Brisbane

      • Wells Foundation
        Community Information center
        Wimbledon Avenue
        Brisbane

        O9 September,2009

        Dear Sir/Madam

        Re :Mr Felix seastin
        DOB:12 January,1952

        I write this letter on behalf of Mr seastine who requires advice on low fat dietary guidelines and healthy simple recepies along with the management of facial acne. He has been recovering from coronary artery bypass graft surgery.

        Mr seastine was admitted to the hospital on o2 of this month and diagnosed with obstructive coronary artery disease . Consequently, he underwent the operation. The postoperative period was uneventful and he is on low fat diet. He was reviewed by a social worker and advised to cease smoking, reduce alcohol . His wound was healed well and he can able to walk.

        Mr seastine lives his house and do home delivery as online business with helps of brother . He smokes 20 cigarettes and drinks two 300ml bottles per day .He consumes fat rich diet with body mass index of 32.3. He also allergic to nuts and oilly food .

        At presently,Mr seastine appears face acne due to excess amount testosterone for which he has been tried hormone reduction medication. He is depressed and uses face cream and washing face over 50 times a day .However, he has suspected for obsessive compulsive disorder.

        It would be greatly appreciated if you could provide dietary guidelines as well as advice regarding facial acne . Kindly do the needful at 9476 Old Dam Road Blessham Q4390

        If you have any doubts denote hesitate to contact me.

        Your’s Faithfully,
        Registered Nurse.

  5. 09 September,2009

    Community Information Section
    Wells Foundation
    Wimbledon Avenue
    Brisbane

    Dear Sir/Madam,

    Re : Mr Felix Seastine,DOB: 12January,1956,BMI: 34

    I am writing to request further advice on low fat dietary guidelines and healthy simple-eating recipes for Mr Seastine who has been recovering from coronary artery bypass. He is being discharged today.

    Mr Seastine was admitted to hospital on 02 of this month for the management of obstructive coronary artery disease and underwent the above mentioned operation successfully. His postoperative recovery was uneventful. While in our care, a low fat diet has been initiated for him. He has been advised to cease smoking and reduce alcohol consumption. Currently, he has made good progress.

    Mr Seastine lives alone and runs his online home delivery business with the help of his brother. He consumes alcohol and smokes in excess. In addition, he prefers to eat fast foods high in fat. It is worth mentioning that he is allergic to nuts and oily food.
    Pertaining to Mr Seastine’s past medical history, he was treated with hormone reduction medications to manage his elevated testosterone levels. He has a warty face due to excess acne, for which he uses face creams and washes his face excessively.
    In view of the above information.

    It would be greatly appreciated if you could provide more practical advice to Mr Seastine regarding the management of acne at 9476 Old Dam Road, Blessham Q4390.

    Please contact me for further information.

    Yours faithfully,

    Simmy Joseph
    Registered Nurse

  6. Sir…Kindly evaluate my letter if you have time.
    I just want to know my level of scoring and writing..waiting hopefully for your valuable feed back..
    Thank you sir…

    09 September,2009

    Wells Foundation
    Community Information Section
    Wimbledon Avenue
    Brisbane

    Dear Sir/Madam

    Re:Mr Felix Seastine,53 years

    Mr Felix Seastine has requested advice on low fat dietary guidelines and more practical advice on managing acne on his face.He has been diagnosed with obstructive coronary artery disease and is being discharged today.

    Mr Seastine underwent coronary artery bypass grafts five days ago and attained routine post operative recovery.He seemed to be depressed as he has warty face due to excess acne.He washes his face more than fifty times a day by using some face creams.He used hormone reduction medications to control excess testosterone.

    Mr Seastine is unmarried and works as an online business man.He drinks 600ml of beer and smokes 20 cigarettes in a day.He consumes deep fried chips,eggs,burger,KFC and sausages regularly.His weight is 99kg and height is 170cm.

    Mr Seastine is allergic to nuts and oily food.He demands food high in fat.He has been advised to stop smoking and control alcohol intake.

    Kindly provide information including simple recipes to manage his acne and send it to his home address.(9476,Old Dam Road,Blessham,043990)

    If you need further details, please do not hesitate to contact me.

    Yours faithfully,

    Simmy Joseph
    Registered Nurse

  7. 09/09/09

    Wells Foundation
    Community information Section
    Wimbledon Avenue
    Brisbane.

    Dear Sir/Madam,
    Re:Mr Felix Seastine,53 Years

    Mr Seastine who is recovering from Coronary Artery Bypass surgery requires advice on low fat diet and practical measures to manage his acne on face.He is being discharged today.
    Mr Seastine was admitted on 2nd of this month and the above mentioned procedure was performed on 4th.Post Opreatively, he made a good prognosis But he is depressed about his wraty face due to excess acne for which he uses face creams. Hehas
    a obecession of washing face over 50 times a day.Additionally, he tried for Testosterone reduction medication .

    Mr Seastine lives alone and work for online business . He smokes 20 cigaretts and consumes 2 bottles of beer per day.Also, he prefers to have high fat diet and he is obese. He was advised to cease smoking and to reduce the consumption of alcohol along with low fat diet but he demands for high fat diet .

    In the light of the above details , it would be greatly appreciated if you could provide more practical advice and healthy simple recipes on managing acne on face.It is worth noting that, The information should be sent to Mr Seastines residential address.

    Yours sincerely,
    Registered Nurse.

  8. The Community Information Section
    Wells Foundation
    Wimbledon Avenue
    Brisbane

    09 September 2009

    Dear Sir/ Madam,

    Re: Mr Felix Seastine,
    DOB: 12 January 1956

    I am writing on behalf of Mr Seastine who requires advice on nutritional and low fat diet along with the management of facial acne. He is being discharged today after coronary angioplasty.

    Mr Seastin lives a sedentary lifestyle who prefers fast foods. In addition, he has been smoking and drinking in excess. He is depressed and has warty face due to acne for which he uses face creams. He also used hormones reduction drugs for excessive testosterone levels. Worth noting, he is allergic to oily food and nuts.

    On 4th of this month, Mr Seastin underwent the surgery owing to obstructive coronary artery disease. Post-operatively, he is recovering well. He has been advised to quit smoking, low fat diet and decrease alcohol consumption. Additionally, he was recommended to continue rehabilitation exercise program. Please note, his weight is around 100 kg and 170 cm of height.

    It would be greatly appreciated if you could provide dietary guidelines regarding: healthy simple recipes and low fat diet to Mr Seastin’s home address. It will be helpful for him if you give more practical advice on management on acne.

    If you requires further information, please contact me.

    Yours faithfully,
    Simmy Joseph
    Register Nurse
    Coronary Care Unit
    St Andrews Hospital
    Brisbane

  9. September 09, 2009

    Community Information Section
    of the Wells Foundation
    Wimbledon Avenue
    Brisbane

    Re: Felix Seastine, 53 years

    Dear Sir/Madam,

    I am writing on behalf of the request of Mr. Seastine for advice on low-fat dietary guidelines and health simple recipes along with relevant advice to manage acne on his face. He is due for discharge today who was diagnosed with obstructive coronary artery disease. He underwent CABG four times last 4th of September and the procedure was remarkably successful.

    Mr. Seastine smoked and drink alcoholic beverages regularly. His BMI is 34.2 above average. In addition, his usual diet includes rich in oil and fat that comes from fast foods such as KFC, Please take note that he has allergic reactions to nuts and oily foods. However, he was suffering excess acne due to excessive testosterone hormone. For this reason, he felt depressed. Hence, he claimed that he uses face-creams to wash his face for over 50 times a day. For which he can also be considered to have obsessive-compulsive disorder.

    An appointment was made for his follow-up visit to local GP Dr. Cinderella at 2 pm on 15th of September. He was also encouraged to continue his rehabilitation exercise program with the local physiotherapist. He was also advised to refrain from smoking and drinking alcohol and to adhere to a proper diet.

    I would be please if you can address the request of Mr. Seastine with regards to his well-being and need for dietary guidelines which is appropriate for his condition. Please note Mr. Seastine’s address 9476 Old Dam Road, Blessham Q4390

    If you have any queries. Please do not hesitate to contact me.

    Yours Sincerely,

    Simmy Joseph
    Registered Nurse

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