Case Notes – Christopher Fort

CASE NOTES 07 CHRISTOPHER FORT

OCCUPATIONAL ENGLISH TEST WRITING SUB-TEST: Nursing

READING TIME: 5 MINUTES | WRITING TIME: 40 MINUTES

NOTES

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

Patient Details

• Name: Mr Christopher Fort
• Age: 49 years
• Married, lives with wife and 2 children
• Address: 1324, Seventh Avenue, Bridge Ford, London
• Height:173
• Weight: 59
• Temp: 98.6°F
• Pulse: 72 b/m
• Blood pressure:150/100 mm of hg

Admission

• Admission date: 20/2/2020 (with chest pain, radiating to shoulder, difficulty breathing – 2 days along with generalized weakness, nausea, dizziness)
• ECG – ST elevation
• Ckmb+
• Dx – Myocardial infarction

Medical History:

• Peptic ulcer
• Twice clipping done
• Hypertension – 8 years, on tab Nicardia 5 mg once daily
• Diabetic – 9 years, Human mixtrad Bd
• Heavy drinker and smoker (10 years)
• Eats oily foods, sugary creams
• Nil exercise

Medications

• Pan 40 mg BD for one month
• Aspirin 325 mg one month
• Statix 40 mg of one month
• Paraffin 10 mg of one month

Investigations Report:

• RBS:190 mg/dl
• FBS:118mg/dl
• LDL:120mg/dl
• HDL:40mg/dl
• HB: 12

21/2/2020

• Angiogram
• Presence of clots in the left side of the coronary artery.
• Percutaneous transluminal coronary angioplasty done.

Post-operative progress:

• No complications.
• Blood pressure and blood sugar under control.

Recommended by dietitian:

• Avoid oily foods and carbohydrates.
• Increase green leafy veggies, fruits and vegetables, fluid intake.
• He is ready to be discharged after the consultation with consultant.

Discharge plan:

• Schedule follow up with Fbs, FLP, reports on 3/3/2020.
• Medication monitoring
• Quit-line programs
• Blood pressure and blood sugar monitoring
• Dietary management
• Encourage daily Exercise
• Follow up
• Avoid strenuous exercise for two weeks.

Writing Task

Using the given information, write a letter to the district nurse, Bridge Ford, London, requesting home visits to ensure medication compliance and dietary restrictions.

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.