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Day 8 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:

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

Ms. Kelly Skotch is a patient in your care at Blacktown Women’s and Girls’ Refuge Center, 6 Prince St, Blacktown, NSW, 2148, Australia. She is 6 weeks pregnant with her first child. She presented two days ago, requesting help for her substance abuse problems. She reports a desire to reduce or cease her alcohol consumption and a desire to reduce a cease her drug use. No desire has been indicated to decrease or stop cigarette use. She now wishes to be discharged but will require ongoing support throughout her pregnancy.

Patient details

  • Name: Ms. Kelly Skotch
  • Age: 21
  • Admission: 8/06/2020
  • Diagnosis: Pregnant substance abuse
  • Discharge: 10/06/2020
  • Plan: Community Mental Health Nursing required daily next 2 weeks minimum.
  • Pt wishes to continue living with a friend (would share the latter’s bed) (Pt extremely attached to this friend (Ms Athens Bleanly) and the friend is addicted to opium but is a great support for Ms Skotch)
  • Psychiatric support needed for depression
    • Methadone program
    • Alcoholics Anonymous meetings
  • 1 Trimester Ultrasound at 2 weeks;
  • Maternal health clinic appointment needed.

Reason for admission:

  • Pt. self admitted due to concern about pregnancy.
  • Confirmed pregnancy test.
  • Reported pain in lower back;
  • Weight loss (6 kg over 2 months)
  • Some memory loss; tingling in feet; difficulty sleeping; excessive worry and hallucinations; feeling depressed (history of depression).
  • No pain in hips or joints; no decrease in appetite; no double vision;

Treatment

  • Pt. monitored and blood tests for HIV/AIDS and STDs.
  • Counselled re-nutrition during pregnancy.
  • Counseled re HIV/AIDS and risk of STD
  • Counselling has been recommended for appropriate nutrition during pregnancy (in addition to the possibility of attending a rehab clinic to address her alcohol and drug issues)

Lifestyle:

  • Nicotine (Daily 30-40 cigarettes; started smoking at 15
  • Drugs used (cannabis, amphetamines, cocaine, heroin – started all from 16 years)
  • Injects heroin, occasionally shares infecting equipment with Ms Bleanly and her friends (men and women)
  • Alcohol max. units/day 15. (Started drinking at 16)

Social History

  • Boyfriend quarreled and left her due to her “mad behavior” and alleged “sexual relations” with Ms Bleanly.
  • No contact with parents (She had hit her mother twice, 4 years ago)

History:

  • Suicidal thoughts, self-harm in past.
  • Seen a psychiatrist but did not follow up. (She tried to run her car over the psychiatrist for referring to her life-style as “extremely wayward.”

Writing Task

Using the notes, write a letter about Ms Skotch’s situation and history to the community health nurse. Address your letter to Ms Petra Cornwallis, Registered Nurse, Community Health Centre, Blacktown.

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 take this Case Notes Analysis and proceed to Letter Writing 

  • Question of

    Who is the patient?

    • A young woman
    • A young pregnant woman
    • An elderly woman
  • Question of

    What is the request to the recipient?

    • Home-care for multiple complications
    • Counselling for multiple complications
    • Admission
    • Ongoing support for multiple complications
  • Question of

    Who is the recipient?

    • Doctor
    • Psychiatrist
    • Community Nurse
  • Question of

    What is the admission / discharge status?

    • Admitted
    • Admitted and Discharged
    • Not admitted (Home visit)
    • Being discharged today
  • Question of

    What is the DoW (Date of writing)

    • 08/06/2020
    • 10/08/2020
    • 10/06/2020
  • Question of

    What is the least important information in the case notes?

    • Social History
    • Substance abuse
    • All the notes of information is equally important
    • Pain in the lower back
  • Question of

    What did the patient start first?

    • Alcohol
    • Drug use
    • Smoking
  • Question of

    Do you think it is going to be easy to change Ms Skotch’s problems?

    • Yes
    • No
    • Will be tough
  • Question of

    Does this case notes contain anything “tricky?”

    • Yes
    • No
  • Question of

    Is the patient already under any treatment?

    • Yes
    • No

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3 Comments

  1. 10 June,2020

    Ms Petra Cornwallis
    Registered Nurse
    Community Health Center
    Blacktown

    Dear Ms Cornwallis,

    Re : Ms Kelly Skotch,21 years

    I am writing to introduce Ms Skotch,6-week pregnant young lady, who requires your ongoing psychiatric support throughout her pregnancy.She has been facing substance abuse related issues and is being discharged today.

    Two days ago,Ms Skotch presented to our center due to concerns about her pregnancy.She also complained about her existing depressive symptoms.On assessment ,her pregnancy was confirmed and was screened for HIV and STDs.While in our care,she has been counselled regarding proper nutrition during pregnancy and the risks of sexually transmitted diseases.

    Ms Skotch has a history of chronic substance abuse including cannabis,cocaine and heroin and occasionally shares injecting equipment with multiple persons.She also consumes15 units of alcohol and smokes 30-40 cigarettes per day.Currently,she lives with her partner Ms Bleanly,who is also an opium addict and allegedly maintaining sexual relationship with her.She has suicidal thoughts and self-harming tendency.Although she is interested to quit her alcohol consumption and drug use,she still wishes to continue smoking.Please note,she has lost 6kg over the past two months.

    In view of the above ,kindly take over the care of Ms Skotch and provide daily mental health nursing services at least for the next two weeks.Please make sure her active participation in Methadone program and Alcoholic Anonymous meetings.Finally,she needs maternal health clinic appointments along with regular ultrasound monitoring every 2 weeks.

    Please contact me for any queries.

    Yours sincerely,

    Registered Nurse

  2. 10 June 2020

    Ms Petra Cornwalls
    Registered nurse
    Community Health Centre
    Blacktown

    Re: Ms Kelly Skotch, DOB: 21 years

    Dear Cornwalls

    I am writing regarding Ms Skotch, who is an antenatal woman, has been using substance. She is being discharged and now, requires ongoing care throughout her pregnancy.

    Ms Skotch presented with a concern of her pregnancy. On assessment, she was experiencing lower back pain, weight loss and memory loss. Various investigations were carried out and confirmed her pregnancy. Thereafter, she has been given counselling regarding nutrition and STD infection. Additionally, she has been advised to attend a rehabilitation clinic in order to address her additive issues. Which resulted in her quitting alcohol and drug usage. However, there is no signs of quitting her smoking.

    Ms Skotch lives with her friend, who is addicted with opioid drugs.In terms of her lifestyle, Ms Skotch consumes 15 units of alcohol and smokes 30 to 40 cigarettes per day. She also uses drugs such as cannabis amphetamines, cocaine and heroin. She has a history of depression along with suicidal attempts and self-harm behaviours,for which she was reviewed by psychiatrists but, she did not follow up.

    In view of the above,it would be greatly appreciated if you could provide assistance to Ms Skotch for two weeks.Please encourage her to participate in Alcoholics Anonymous as well as methadone program and kindly arrange her to get psychiatric support for her depression. Please be aware that she requires follow up visits at maternal health clinic in order to carry out her ultrasound scan.

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

    Yours sincerely

    Registered Nurse

Written by Biju John

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