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.
You are a Registered Nurse at the Queensland City Hospital were Rosario Lebanon is a patient in your care.
Today’s date: 29/05/2017
Patient name: Mr Rosario Lebanon
Address: Unit 12, 65 White Street, Brisbane 4800
Age / DOB: 19/07/1931
Next of Kin: Son, Jewel Lebanon, 52 years old, unmarried – lives 30 minutes away
Dx Klinefelter’s syndrome (when he was 17 years)
Orchiectomy (when he was 19 years; Right testicle removed)
Dx Breast Cancer 20 years ago, right total mastectomy (same year).
Did not receive adjuvant radiation, chemotherapy, or hormone therapy or medical follow-up post-operatively.
Diagnosis: Recurrent infiltrating ductal carcinoma of the breast.
Other conditions / details: Dementia, Non-smoker, No known allergies, Non-drinker
Mother died of colon cancer (68 years)
Retired 20 years ago as fabrication manager,
Married – Wife (Evania M Lebanon) suffering from newly onset dementia
Presented to ER with ulcerated, hemorrhaging right anterior chest mass
Developed a mass on his anterior chest wall – 2 years ago
Mass increased in size, began to ulcerate – bled this morning — did not seek medical treatment until this morning
- Temperature – 97.4°F
- Pulse- 80 RR – 14
- Pulse oximetry of 100% on room air
- BP – 162/88.
A right-sided pedunculated 8 cm × 7 cm mass with a cauliflower-like appearance on chest – ulcerated, erythematous, malodorous, and with scant bleeding.
- White blood cell count 6,500
- Haemoglobin 12.4
- Haematocrit 36.2
- Platelet count 178,000.
- Creatinine of 1.72 Glucose 106
A CT chest – a soft tissue mass in right chest wall measuring 5.2 × 2.75 × 5 cm with postoperative changes of the right axilla. Incisional biopsy of right breast mass performed.
Pathology returned consistent with recurrent moderately differentiated duct carcinoma of the breast with ulceration of overlying epithelium (Stage 3).
Pt. not found to be suitable for chemotherapy or curative treatment
Oncology evaluation and geriatric evaluations by doctor.
Pt. commenced on hormone therapy with tamoxifen 20 mg daily with one course of palliative radiation.
Family meeting called. Son verbalized concerns over mother’s state of health;
(Son unable to take time off work to care for father – Says he won’t be able to cope)
Hospice care recommended for pt (Consensus decision)
Pt. to be transferred to Queensland Aged Care Centre for hospice care.
Bed available from 29/05/2017 for patient.
Mrs Lebanon to be admitted to the same facility due to general deconditioning when bed is available; Now to live with son interim.
- Transfer to Aged Care home
- Son will visit weekly
- Contact community social worker to notify son when bed available for wife at Queensland Aged Care Center.
Using the information in the case notes, write a referral letter to the Ms Perry Smith, Director of Nursing, Queensland Aged Care Center, 80 Ferdinand Magellan Block, Brisbane 4191, introducing the patient. Using relevant case notes, give his background, medical history, and treatment required.
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
Adjuvant radiation is a therapy:
What is the purpose of this letter?
Aged Home Admission
Who is the recipient of this letter?
Nurse in charge of home visit
Nurse at aged care home
Nurse at a hospital
How many patients are being referred in this case notes?
For whom is this letter is written?
Why is the patient not getting any chemotherapy or curative treatment?
The patient is not suitable
The patient has refused to
The patient’s relatives have disagreed
What is the admission / discharge status?
Being discharged today
Will be discharged tomorrow