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Case Notes 19.4 – Mikkel Ullrich


Writing Sub-Test – Nursing

Reading time – 5 minutes
Writing time – 40 minutes

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


Today’s Date: 15/8/2023

You are a nurse working in the Windon International Hospital, Sydney. A patient, Mr Ullrich has been admitted to your unit from the emergency department, after a car accident.

Patient Details

  • Name: Mikkel Ullrich
  • Age: 69 years
  • Marital Status: widower
  • Admission Date: 6/8/2023
  • Discharge Date: 15/8/2023
  • Diagnosis: fracture of tibia and fibula

Social, Economic, Psychological Background

  • Lives in Windon, Rental flat.
  • Income: Retired school teacher
  • Primary care giver: Son (Jonas)
  • Financial difficulties ++
  • Applied for aged pension
  • Episode of depression after wife’s death.
  • Lack of socialization (has few friends).

Admission details: 6/8/2023

  • Reason: Leg fracture – Road traffic accident
  • Multiple injuries +++
  • Severe blood loss. 3-unit pcv transfused
  • Left leg below knee amputation done


  • Moderate fever;
  • Antibiotic dose increased
  • Pain 7/10


  • Fever +++ Paracetamol 500 mg given.
  • Persistent pain. Wound dressing done.


  • Afebrile, physiotherapy started.
  • Occupational therapy + psychological counselling given.
  • Dressing done.


  • Ready to be discharged.
  • Wound dressing + wound clean and dry.
  • No signs of infection. ? Depressed

Discharge plan

  • Social worker reference for assistance and continuation of services at home.
  • Home modifications
  • Need Walking aids and toilet raiser
  • Continue physiotherapy and occupational therapy after discharge
  • Wound dressing daily – community nurse
  • Follow up after 14 days
  • Connect to local support groups

Writing Task

Using the information in the case notes, write a referral letter to Mr Noah Tiedman, social worker, Adams street, Windon, Sydney.

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.

What do you think?

Written by English Melon

Biju John, author of ByeBle and Maclins, is an English Language Trainer. He has also authored his educational Fiction. All these titles are available on Amazon and Google. You can contact his office on WhatsApp / Telegram number +917510923061

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