Case Notes 57.1

Case Notes 57.1 Janice Brown

Occupational English test – Writing (Nursing)

Instructions:

• You have 45 minutes to write this letter.
• During the first 5 minutes, you should not pick the pencil.
• Start writing only when you are told.
• During the Reading Time, try to understand the case notes.

Melons Steps

• Mark (M) PPRRAADDDDDWK.
• Eliminate (E) irrelevant information.
• Launch (L) the letter with DADR.
• Open (O) the letter with PRPDD or PRPTT.
• Narrate (N) the remaining paragraphs using V or W.
• Sign (S) the letter with S/F.

Melons Errors

• Punctuation “Marks”.
• Follow “Expansion” Rules.
• Obey “Language” Rules.
• Have an “Order” (DADR, PRPDD, V/W, S/F)
• Do not change “Names”.
• Sex (Mr, Ms, Mrs, His, Her).

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

Notes:

Imagine that today is August 14, 2024. You are in charge of this patient at City Hospital, High Gate, Waterloo, UK.

Patient Details

• Name: Janice Brown.
• Age: 85
• Residence: Sunny Meadows Old Age Home (since husband’s death).
• Marital Status: Widowed (husband passed away 10 years ago)

Medical Background

• Type 2 Diabetes Mellitus (diagnosed 22 years ago).
• Osteoarthritis (diagnosed 10 years ago).
• Chronic Kidney Disease (Stage 3). Diagnosed 3 years ago.
• History of Stroke (2019).
• Allergy: Penicillin (rash, difficulty breathing).
• Father and mother had kidney disease.

Recent History

• Admitted with confusion and generalized weakness.
• Increased lethargy and decreased oral intake.
• New onset of shortness of breath.
• Uncontrolled blood sugar levels.
• Weight loss of 4 pounds in the past month.

Admission & Discharge

• Admission Date: 10 August 2024.
• Discharge Date: 15 August 2024
• Diagnosis: Exacerbation of Chronic Kidney Disease, Uncontrolled Diabetes Mellitus.

ED Record

• Vitals on Admission: Temp 37.8°C, HR 105 bpm, RR 20, BP 160/95 mmHg, O2 Sat 89% on room air.
• Labs: Elevated creatinine 2.5 mg/dL, Blood glucose 320 mg/dL, HbA1c 9.5%.
• Treatment in ED: IV fluids, insulin therapy, oxygen therapy.

Nursing Care

• Daily monitoring of vital signs and blood glucose levels.
• Assistance with activities of daily living (ADLs).
• Encouraging fluid intake and balanced diet.
• Frequent repositioning to prevent pressure ulcers.
• Physical therapy to improve mobility.
• Patient education on diabetes management.

Discharge Medications

• Metformin 500 mg twice daily.
• Lisinopril 20 mg daily.
• Glipizide 5 mg daily.
• Aspirin 81 mg daily.
• Multivitamin daily
• Calcium with Vitamin D supplement daily

Discharge Plan

• Follow-up appointment with GP Dr. Michael Spencer in 1 week.
• Regular blood glucose monitoring.
• Repeat kidney function tests in 1 week.
• Continue daily vital signs and assessments.
• Monitor for signs of hyperglycemia or hypoglycemia.
• Ensure proper hydration and diet management.
• Equipment Required: Walker, Blood glucose monitor, Nebulizer

Writing Task

Using the information in the case notes, write a letter to Ms. Richa Howard, head nurse at Sunny Meadows Old Age Home, 456 Meadow Lane, Norwich, where the patient will return after discharge, tomorrow.

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.