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Day 22 Case Notes Analysis

OCCUPATIONAL ENGLISH TEST

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

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

Notes:

You are the charge nurse of the medical ward, Universal health Care, Sydney. You are planning to discharge the following patient and to arrange follow-up visits with his GP at the place where the patient lives.

Patient Details

  • Name: Mr Luis Morgan
  • DOB: 7th August, 1955

Social History:

  • Indigenous clerk,
  • ex-smoker until last year, until then smoked 10-15 cigarettes daily for 35 years.

Past medical history:

  • Anterior myocardial infarction 2 years ago,
  • Coronary angiogram
  • Inoperable coronary artery disease,
  • Hypertension and type 2 diabetes mellitus for 10 years.

Current Medications:

  • Glibenclamide 10 mg,
  • Metformin 500 mg but not compliant,
  • Reluctant to commence insulin,
  • Furosemide 40 mg, aspirin 75 mg

12 January 2010, 07:00 am

Subjective:

  • Brought into emergency department by ambulance at 7 in the morning,
  • Acutely breathless, looked extremely unwell,
  • Unable to speak, sitting up gasping for breath

Objective:

  • Mildly obese, cold, sweaty, cyanosed, pulse weak, rapid and irregular,
  • BP 160/100 mmHg.
  • Jugular venous pressure-elevated to jaw,
  • heart sounds inaudible,
  • Inspiratory crepitation,
  • Mild pitting oedema.

Assessment:

  • ?Congestive heart failure probably due to recurrent infarction.

Treatment:

  • Immediate treatment (oxygen, 100 mg IV furosemide, 5 mg IV morphine, glyceryl trinitrate 600 mcg)
  • ECG, CXR, insert urinary catheter

12 Jan, 2010, 07:30 am

Subjective:

  • Still acutely short of breath, all other symptoms remain

Objective:

  • Elevated glucose (18.3 mmol/L),
  • Elevated serum creatinine (0.19 mmol/L),
  • ECG consistent with acute inferior infarct with atrial fibrillation,
  • CXR-obvious cardiomegaly &pulmonary edema.

Assessment:

  • Heart failure secondary to recurrent myocardial infarction.

Plan:

  • Start IV isosorbide dinitrate,
  • Oral digoxin,
  • IV heparin,
  • Monitor intensively.
  • Transfer to coronary care unit.

13 Jan, 2010

Subjective:

Improved considerably, now able to walk, admits-unwell for 2 days, mild chest discomfort on the day before admission, was planning to see community doctor but became acutely short of breath, called ambulance.

Objective:

Blood sugar level- well controlled, all the signs-significantly improved.

Plan:

  • Stop nitrate infusion,
  • Continue other medication,
  • Echocardiogram

14 Jan, 2010

Subjective:

Has made gradual recovery, now ready to be discharged, can walk along the corridor for 15 minutes without breathlessness.

Objective:

Heart-lungs-kidneys’ function stable. Echocardiogram-moderately dilated left ventricle with mild mitral regurgitation, functional impairment-moderate.

Plan:

  • Change the current medication into oral forms (furesmide, aspirin, digoxin, warfarin, twice daily insulin)
  • Refer to his GP for regular follow-up visits & dosage adjustment.

Writing Task:

Using the information in the case notes, write a letter of referral to Dr Susan Wang, general practitioner at the family care clinic, 1009 Melbourne Street, North Adelaide, SA 5006.

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.

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.

Proceed to “Praatdwk” Analysis:

  • Question of

    Patient Purpose Recipient Admission Condition Admission Date Discharge Date Discharge Condition Writer Known / not Known

    • Yes
    • No

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