Here is Day 1 Case Notes.
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 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 Nurse Practitioner at the Medical Center Brisbane.
- Name: Sydney Loten
- DOB: August 14, 1946
- Address: 5 Peanut Hedge, Carina Heights QLD
- Phone: 07 86734214
- Next of kin: Eby Simmons (adopted son)
- Retired Professor; widow, an adopted son 24-year-old student; husband died 2014.
- Lives with her son in a one-storey house, son is often unavailable to care for patient due to school and work.
- Oxygen readily accessible at home via nasal cannula at 2-4L as needed
- Height: 160 cm Wt. 65 kg
- Occasional alcoholic beverage drinker. 1-2 bottles of beer/week (till 2019, Jan; 1 bottle of beer/week (now)
- Smoker, 10-15 sticks/day for 35 years (till 2018); 5 e-cigarettes (since then)
- No previous or surgical procedures
- Diagnosed with COPD in 2010,
- Maintained on Ipratropium bromide inhaler, 1 puff,
- Budesonide + Formoterol, 2 puffs BID and
- Prednisone 40 mg taken as a single daily dose for acute attacks
- Diabetic since 2007,
- Metformin 500mg BID, Glipizide 5mg OD
- Hypertensive since 2008,
- Losartan 40mg OD
Patient underwent routine colonoscopy, multiple polyps found.
Admitted at Medical Center Brisbane on April 11, 2020.
Colon polypectomy on April 13, 2020
- Post-op complications at the recovery room, experienced respiratory distress, Arterial Blood Gas revealed. Covid19 test negative.
- Metabolic acidosis. Transferred to ICU and moved to regular ward on April 15, 2020
- Hooked to oxygen support at 3-5L NP as needed.
- Patient uncooperative at times and requires encouragement to take medications.
- Difficulty in sitting and cannot walk around the room.
- Pain meds given as prn:
- Paracetamol 1g IV
- Endone 2.5 mg PRN for intolerable pain
- On laxative,
- Senna, OD at bedtime.
- Was on folly catheter now with adult diaper due to incontinence.
- Stable vital signs at regular ward
- O2 sat at 96-97% at 2-3L.Wean if able to tolerate 1L.
- Moderate post op pain, wound with no exudates
April 17, 2020
- Patient hesitant to ambulate around her room.
- Prefers to walk with assistance.
- Unable to tolerate O2 at 1L. O2 sat at 98% at 2L.
- Anxious during wound dressing.
- Minimal pain at the incision site. Encouraged sitting, standing and walking inside her room. Poor appetite. Constipation, resolves with laxative.
April 19, 2020
Patient walks around her room with walker. Can walk along the hospital corridors but requires increase to 3L O2 after walking. O2 sat at 98% at rest. Less uneasy during dressing change. Improved appetite.
April 22, 2020
Patient can walk with a cane. Can tolerate O2 at 1L, O2 sat 98%. Minimal pain at incision site. Regular bowel movement. Still requires adult diapers for incontinence. Eager to go home. Discharge will be facilitated once O2 availability at home is confirmed.
April 23, 2020
- Patient is ready for discharge. Home medications and instructions given in the presence of her son.
- Need for transition care program explained.
- Continue dressing change at home.
- Advised to monitor O2 consumption. Follow up check-up scheduled on April 30. 2020.
Given the patient’s current situation, you need to write a formal letter to the Nursing Director, Jane Hall of Southern Valley Community Transition Care Program, 64 Gladstone Road, Highgate Hill Qld 4101. Discuss the need of the patient’s continuity of care at home.
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:
Who is the primary patient?
Ms Sarah Marshall
Mrs Sarah Marshall
What is the purpose of this letter?
Needs transfer to another hospital
Needs transition to home
Needs transition to a care center
Is there another patient in this case notes?
Who is the recipient of this letter?
Nurse in charge
What is the (approximate) date of writing (DOW) this letter?
Date not provided
Which information is least relevant?
Information about adopted-son