Case Notes – Sydney Loten
- April 27, 2023
- Posted by: English Melon
- Category: OET
OCCUPATIONAL ENGLISH TEST
WRITING SUB-TEST: Nursing
TIME ALLOWED: READING TIME: 5 MINUTES | WRITING TIME: 40 MINUTES
Read the case notes below and complete the writing task which follows.
You are a Nurse Practitioner at the Medical Center Brisbane.
- Name: Sydney Loten
- DOB: August 14, 1946
Address: 5 Peanut Hedge, Carina Heights QLD
- Phone: 07 86734214
- Next of kin: Eby Simmons (adopted son)
- Retired Professor; widow, an adopted son 24-year-old student; husband died 2014.
- Lives with her son in a one-storey house, son is often unavailable to care for patient due to school and work.
- Oxygen readily accessible at home via nasal cannula at 2-4L as needed.
- Height: 160 cm Wt. 65 kg
- Occasional alcoholic beverage drinker.
- 1-2 bottles of beer/week (till 2019, Jan; 1 bottle of beer/week (now)
- Smoker, 10-15 sticks/day for 35 years (till 2018); 5 e-cigarettes (since then)
- No previous or surgical procedures
- Diagnosed with COPD in 2010, maintained on Ipratropium bromide inhaler, 1 puff, Budesonide + Formoterol, 2 puffs BID and Prednisone 40 mg (taken as a single daily dose for acute attacks)
- Diabetic since 2007, Metformin 500mg BID, Glipizide 5mg OD
- Hypertensive since 2008, Losartan 40mg OD
- Patient underwent routine colonoscopy, multiple polyps found.
Admission, Diagnosis, Management
- Admitted at Medical Center Brisbane on April 11, 2020.
- Colon polypectomy on April 13, 2020
- Post-op complications at the recovery room, experienced respiratory distress, Arterial Blood Gas revealed.
- Covid19 test negative.
- Metabolic acidosis. Transferred to ICU and moved to regular ward on April 15, 2020
- Hooked to oxygen support at 3-5L NP as needed.
- Patient uncooperative at times and requires encouragement to take medications.
- Difficulty in sitting and cannot walk around the room.
Pain meds given as prn:
- Paracetamol 1g IV
- Endone 2.5 mg PRN for intolerable pain
- On laxative, Senna, OD at bedtime.
- Was on folly catheter.
- Now with adult diaper due to incontinence.
- Stable vital signs at regular ward
- O2 sat at 96-97% at 2-3L.
- “Wean” if able to tolerate 1L.
- Moderate post op pain, wound with no exudates
April 17, 2020
- Patient hesitant to ambulate around her room.
- Prefers to walk with assistance.
- Unable to tolerate O2 at 1L. O2 sat at 98% at 2L.
- Anxious during wound dressing.
- Minimal pain at the incision site.
- Encouraged sitting, standing and walking inside her room.
- Poor appetite. Constipation, resolves with laxative.
April 19, 2020
- Patient walks around her room with walker. Can walk along the hospital corridors but requires increase to 3L O2 after walking.
- O2 sat at 98% at rest.
- Less uneasy during dressing change.
- Improved appetite.
April 22, 2020
- Patient can walk with a cane.
- Can tolerate O2 at 1L, O2 sat 98%.
- Minimal pain at incision site.
- Regular bowel movement.
- Still requires adult diapers for incontinence.
- Eager to go home.
- Discharge will be facilitated once O2 availability at home is confirmed.
April 23, 2020
- Patient is ready for discharge. Home medications and instructions given in the presence of her son.
- Need for transition care program explained.
- Continue dressing change at home.
- Advised to monitor O2 consumption.
- Follow up check-up scheduled on April 30. 2020.
Given the patient’s current situation, you need to write a formal letter to the Nursing Director, Ms Jane Hall, Southern Valley Community + Transition Care + Program, 64 Gladstone Road, Highgate Hill Qld 4101. Discuss the need of the patient’s continuity of care at home.
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.