Day 3 Case Notes Analysis

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:



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


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:

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  1. 09 September,2009

    Community Information Section
    Wells Foundation
    Wimbledon Avenue

    Dear Sir/Madam,

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

    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 graft. 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 depends on home-delivered fast foods which are high in fat .In addition to this ,he consumes alcohol and smokes in excess. Please note that he is allergic to nuts and oily foods. His height is 170 cm and currently weighs 99 kg.

    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 guidelines to Mr Seastine for the management of his facial acne. Kindly note that he resides at 9476 Old Dam Road, Blessham Q4390.

    Please contact me for further information.

    Yours faithfully,

    Simmy Joseph
    Registered Nurse

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Case Notes & Analysis 3

Day 1 Case Notes & Analysis (Med)