OET Case Notes 6.1 – Nursing

Occupational English Test – Writing case Notes | 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.

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

Notes:

Today’s Date: 04/03/2024

You are a registered nurse in the Coronary Care Unit, St. John’s Hospital, London. Jamie Morgan is a patient in your care.

Patient Details

• Name: Jamie Morgan.
• DOB: 22 February 1967.
• Address 9476 Old Dam Road, Barona, London.
• Next of Kin Brother, Justin Morgan 72, Burke St, Old Ormond Street, Queensland, Australia.
• Admitted: 28/02/2024
• Diagnosis: Obstructive Coronary Artery Disease
• First treatment planned: CABG
• Treatment Provided (due to fear of complications): Percutaneous Coronary Intervention (30/02/2024)

Social History

• Never married
• Lives alone in own home at Barona, London.
• Computer trainer, Android app developer.

Medical History

• Smoked 30 cigarettes/day until admission;
• Has been compliant to sudden smoking cessation;
• Alcohol: 3 x 300 ml bottles beer / day, till admission date;
• 177 cm; Wt. 96 kg (stable for last 15 years)
• Usual diet: Sausages, deep fried chips, burgers, eggs, MacDonald’s
• Allergic reaction to peanuts

Nursing Management and Progress

01/03/2024

• Routine postoperative recovery but slow;
• Smoking nil, alcohol nil
• Low fat diet
• Walking with a little limping;
• Wounds healing
• Routine visit from Social Worker, Physiotherapist;

03/03/2024

• ? Mild injury to the heart arteries, including tears / rupture.
• No infection, bleeding, or bruising at the catheter site.
• No allergic reaction to dye.
• No kidney damage (from the dye or contrast).
• Blood clots suspected;
• Patient not in critical condition; Can travel.

Current Medicines:

• Clopidogrel 75 mg BD increased to 300 mg nightly.

Discharge Plan

• Returning Home to Barona and then moving to Australia to stay with Mr Justine Morgan on 07/03/2024.
• Appointment made for follow up visit to Dr Sigmund Steve, 02 pm on 11/03/2024 at the doctor’s clinic.
• Local physiotherapist to continue rehabilitation exercise program till departure to Australia.

Writing Task

Using the information in the case notes, write a letter to Dr Sigmund Steve, Cardiovascular Surgeon at Caredio, New Ormond Street, Queensland, Australia. In your letter, list out Mr Morgan’s recent medical history and discharge plan.

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. However, you needn’t include any irrelevant information to reach the word-count; nor do you have to omit any information to avoid exceedance.