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OET Case Notes – Sydney Loten

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.

NOTES

You are a Nurse Practitioner at the Medical Center Brisbane.

Patient Details:

  • Name: Sydney Loten
  • DOB: August 14, 1946
  • Address: 5 Peanut Hedge, Carina Heights QLD
  • Phone: 07 86734214
  • Next of kin: Eby Simmons (adopted son)

Social History:

  • 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

Medical History:

  • 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

Medical Records

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.

WRITING TASK

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:

  • Question of

    Who is the primary patient?

    • Ms Sarah Marshall
    • Mrs Sarah Marshall
    • Sydney Loten
  • Question of

    What is the purpose of this letter?

    • Needs transfer to another hospital
    • Needs transition to home
    • Needs transition to a care center
  • Question of

    Is there another patient in this case notes?

    • Yes
    • No
  • Question of

    Who is the recipient of this letter?

    • Nurse in charge
    • Head Nurse
    • Nursing Director
  • Question of

    What is the (approximate) date of writing (DOW) this letter?

    • April 24
    • Date not provided
    • April 23
  • Question of

    Which information is least relevant?

    • Information about adopted-son
    • Husband’s death
    • Past profession

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14 Comments

  1. 23 April 2020

    The Nursing Director
    Jane Hall Of Southern Valley
    Community transition care program
    64 Gladstone Road
    Highgate Hill
    QLD 4101

    Dear sir/ madam,
    Re: ms Sydney Loten, DOB: 14 August 1946

    I am writing to request homevisit for ms Loten for continuing of care , as she developed metabolic acidosis following colon polypectomy.
    On 11 April 2020, ms Loten was admitted for colonoscopy and found multiple polyps . Therefore, she underwent the aforementioned procedure . Post-operatively, she developed respiratory distress owing to metabolic acidosis for which she was provided oxygen support. Her pain was managed with analgesic.

    During hospitalization, ms Loten showed a good prognosis as evidenced by walking with support. She Maintains saturation of 98% at 1 litre of oxygen and her bowels are normal, however she requires diaper for in continence.

    Ms Loten ,who is a widow, has an adopted son.she has habit of drinking beer occasionally and smokes 5 cigarettes a day . She has had COPD, diabetes and hypertension since 2010,2008,2007 for which she is on medications.

    As per the discharge plan, it would be greatly appreciated if you could educate her the need for transition care program. It is good idea to continue her dressing and monitoring oxygen consumption. Of note, she is due for follow-up check-up on 30 April 2020.

    Please do not hesitate to contact me.
    Yours faithfully,

    Nurse practitioner
    Medical centre
    Brisbane

    • Date – Okay
      Address – Punctuation errors (Capitalize first letters of Transition, Care, Program, etc)
      Salutation – Capitalize S and M
      Subject: Same punctuation errors; for too old patients, better convert DOB to “xx years”

      Para 1
      1. No need of comma before “as she developed”
      2. Do not repeat year / month if the event happens in the same month / year of writing the letter.

      + 7 other errors. Please improve language.

  2. Letter by Merlin john
    The Nursing Director
    Jane Hall of Southern Valley Transition Care Program
    64 Gladstone Road
    Highgate Hill Qld 4101

    23April,2020

    Dear Sir/Madam

    Re:Ms Sydney Loten
    Age:74Years

    Ms Sydney Loten requires continued care at home as she underwent colon polypectomy.She is set to be discharged today.

    Ms Loten was admitted to hospital after routine colonoscopy.She was found to have multiple polyps; therefore,the surgery was performed on April 13,2020.Postoperatively,she showed the signs of respiratory depression for which 3-5 litter oxygen support through nasalcanula was initiated.She is negative for covid 19test.She was treated with various medications for pain, constipation and poor appitate.Now,she maintained oxygen saturation 98 % with 1litter of oxygen,which needs to continue.she can mobilize with cane.she has regular bowel pattern; however,she still requires diapers.

    Ms Loten is a widow who lives with her 4year old adopted son.She is a heavy smoker and drinks occasionally.She has had diabetic mellitus, hypertension as well as chronic obstructive pulmonary disease since 2007,2008,and2010 respectively.She has been taking regular medications.

    Ms Loten needs oxygen and medication monitoring .She requires daily dressing change.Please note,her follow up visit is due for 30April,2020.

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

    Yours sincerely,
    Nurse practitioner
    Brisbane medical centre

  3. 23.04.2020
    Nursing Director
    Jane Hall of Southern Valley Community Transition Care Program
    64 Gladstone Road
    Highgate Hill Old 4101

    Dear Nursing Director,
    Re: Ms Sydney Loten DOB: 14.08.2020

    I am writing to request continuity of care for Ms Loten who had undergone colon polypectomy on 13.04.2020.
    Ms Loten was admitted at Medical Center Brisbane on 11.04.2020 and underwent colon polypectomy as result of colonoscopy findings. Due to post operational complications, she was transferred to ICU for 2 days and then was moved to regular ward. Firstly, he was not able to ambulate and experienced pain, discomfort and dyspnea while sitting for which she was given oxygen, analgesics and laxatives. On 23.04.2020 after a huge recovery in her condition, she is ready to discharge as she is able to walk alone.
    Ms Loten is a retired widow professor and lives with her 24-year-old son who attends school and can not help with patient’s care. She drinks, smokes and takes oxygen via nasal cannula at home as needed. She sufferes from COPD, diabetes and hypertension for which she receives medications regularly.
    On today’s visit, all medications and instructions were given in the presence of her son and she was advised to monitor oxygen saturation and a follow up visit was scheduled on 30.04.2020.
    In view of the above, she needs for transition care as prescribed and change dressing at home. Please, do not hesitate to contact if you require any information.

    Yours faithfully,

    Nurse practitioner
    Medical Center
    Brisbane

    • 1. Dear Nursing Director > Dear Sir / Madam
      2. Incorrect date of birth, better specify the exact age.
      3. Incorrect use of had in “who had undergone…”. Just write who underwent…
      4. As result of > as a result of
      5. Interchange of he for she (maybe typing error but it will be seriously seen)

      11 more errors.
      Score 320 or less.

  4. 23rd April, 2020

    The Nursing Director
    Jane Hall Of Southern Valley
    Community Transition Care Program
    64 Gladstone Road
    Highgate Hill
    QLD 4101

    Dear Sir/ Madam,

    Re: Ms Sydney Loten, 74 years old

    I am writing to request a continuity of care and management for Ms Loten who underwent colon polypectomy. She is being discharged home today.

    On the 11th of this month, Ms Loten was admitted to the hospital for the aforementioned procedure. During hospitalization, Ms Loten showed a good prognosis as evidenced by ambulation with a support of a cane and she is able to maintain her oxygen saturation to 98% at 1 liter. Her bowels are now normal. However, she requires diaper for her incontinence.

    Socially, Ms Loten is a widow and lives with her adopted son, Eby Simmons, who is not able to take care of her for he is studying and working at the same time.

    In terms of medical history, Ms. Loten has COPD, diabetes and hypertension since 2010, 2008, 2007 respectively for which she is on medications. She is an occasional drinker and a chronic smoker.

    As per the discharge plan, it would be greatly appreciated if you could educate her the need for transition care program. Kindly continue her daily wound dressing change and to monitor her oxygen consumption. Please note, she has a follow-up check-up on the 30th.

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

    Yours Faithfully,

    Nurse Practitioner
    Medical Centre
    Brisbane

  5. Nursing Director
    Jane Hall
    Southern Valley Community
    Transition care program
    64 Gladstone Road, Highgate Hill Qld 4101
    23rd April, 2020

    Dear Madam/ Sir

    Re: Sydney Loten, Aged 73.

    I am writing to request a home visit for Mrs Loren, a 73-year-old widow who requires a continued care at home, your care and management would be highly appreciated.

    Mrs Loren is a Retired Professor, she has an adopted son, a 24-year-old student, Mrs Loten lives with her son in a one storey house, but her son ia often unavailable to care for her due to school and work, Mrs Loren is on oxygen and it is readily accessible at home via Nasal cannula at two litres as required.

    As regard Mrs Loren medical history, she has been diagnosed with Chronic Obstructive Pulmonary Disease, diabetes, hypertension and was placed on some Media, however on 11th of April, Mrs Loten underwent routine colonoscopy, result revealed multiple polyps, on 13th of April Colon Polypectomy was performed, she was well cared for post operatively, Mrs Loren can now walk with a cane, she can also tolerate oxygen at one litre, oxygen saturation at 98%, minimal pain at incision site, there is regular bowel movement, Mrs Loren still requires adult diapers for incontinence.

    In view of the above Mrs Loren now requires further care and management at home following her discharge, her medication and instructions on how they are to taken has been given to Mrs Loren in the presence of her son, wound dressing would also Abe continued at home oxygen consumption should also be monitored, your promt visit to Mrs Loren would be highly appreciated. Please do not hesitate to contact me for further queries.

    Yours sincerely

    Charge Nurse.

  6. 23 April 2020
    Nursing Director
    Jane Hart of Southern Valley
    Community Transition Care Program
    64 Gladstone Road
    Highgate Hill Qld 4101

    Dear sir/madam,

    Re: Sydney Loten,aged 74 years
    I am writing to request a home visit Ms.Loten who had Polypectomy.She needs further care and management from your facility.She is being discharged today.

    On 11 April 2020 Ms.Loten was admitted for routine colonoscopy and multiple polyps found.Therefore, she underwent surgery. During postoperative period she experienced respiratory distress. She commenced with Paracetamol 1gm IV,Endone 2.5mg PRN for pain and laxative.She is on adult diaper due to incontinence of urine.Her 02 saturation was 98% at 2litre and now she can tolerate o2 at 1litre.

    Ms.Loten is a retired Professor and she adopted a 24years old student as son.She is a widow and lives with son.Ms.Loten has been diagnosed with COPD,Diabetes and HTN.She smokes 10-15 sticks per day and drinks occasionally.

    In view of the above it would be greatly appreciated if you could artange for dressing at home. Kindly monitor o2 consumption.She was advised for Transition care Program. Her follow up check up has scheduled on 30 April 2020.

    Please do not hesitate to contact me if you need information.

    Yours sincerely
    Registered nurse

  7. The Nursing Director
    Jane Hall
    Southern Valley
    Transition Care Program
    64 Gladstone Road
    Highgate Hill QLD 4101

    23 April, 2020

    Dear sir/Madam,

    Re: Ms Sydney Loten, D. O. B: 14/08/2020

    Ms Loten who underwent colon polyperstomy requires continued care at home from your facility. She is being discharged today.

    On 11th of this month Ms Loten was admitted to hospital after routine colonscopy. She was found to have multiple polys. Therefore, the surgery was performed on 13th of this month. Postoperatively, Ms Loren showed the signs of respiratory distress for which 3-5liter oxygen support was initiated through nasal cannula. She was treated with various medication for constipation, pain, and for poor appetite.

    At present, Ms Loten maintained oxygen saturation 98% with 1 liter of oxygen, which needs to be continued. She is able to mobilize with cane. Even though she has regular bowel pattern, she still requires diapers. She is negative for covid 19 test.

    Ms Loten is a widow who lives with her 4 year old adopted son. She has the habit of smoking and drinks occasionally. She has had diabetic melliticus, hypertension as well as chronic obstructive pulmonary disease since 2007,2008, and 2010 respectively. Hence, she has been taking regular medications.

    It would be greatly appreciated of you could monitor Ms Loten’s medical compliance and need for oxygen. Kindly perform daily dressing for her. Please note, her follow up visit is scheduled on 30th of this month.

    If you have any queries regarding Ms Loten, please do not hesitate to contact me.

    Yours faithfully,
    Registered Nurse

    • The Nursing Director
      Jane Hall of Southern Valley
      Community Transition Care Programme
      64 Gladstone Road
      High gate Hill Qld, 4101

      23 April,2020

      Dear Sir/Madam,

      Re:Ms Sydney Loten,73 years old

      I am writing to refer Ms Sydney Loten who underwent colon polypectomy,requires continued care at home.She is being discharged today.

      Ms Loten was admitted on 11 April,2020 following routine colonoscopy which revealed multiple polyps, hence she has undergone the surgery.Postoperatively,she developed respiratory distress which necessitated icu admission for 2 days.Later, she was managed in regular ward with minimal oxygen support and necessary pain killers.She is able to ambulate short distances;however requires oxygen after walking.Apart from this,her constipation is resolving but she needs diaper for urinary incontinence.

      Ms Loten has multiple medical ailments such as COPD,diabetes,and hypertension for which she is on regular medications.She lives with son,who is often unavailable to care for her due to school and work.She consumes alcohol occasionally and smokes cigarettes.

      Ms Loten requires monitoring of medication and oxygen consumption.It is important to change her insicion site dressing daily.She was advised on the need for transition care program.Her follow up is due on 30,April,2020
      Please contact for further queries.
      Yours sincerely,
      Nurse Practitioner

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