Case Notes 19.4 – Mikkel Ullrich

OCCUPATIONAL ENGLISH TEST

Writing Sub-Test – Nursing

Reading time – 5 minutes
Writing time – 40 minutes

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

Notes

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

7/8/2023:

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

9/8/2023:

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

10/8/2023

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

14/8/2023:

• 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.