Case Notes – Sydney Loten

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.

Patient Details:

• Name: Sydney Loten
• DOB: August 14, 1946

Address: 5 Peanut Hedge, Carina Heights QLD

• Phone: 07 86734214
• Next of kin: Eby Simmons (adopted son)

Social History:

• 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.

Medical History:

• 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

Medical Records

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.

WRITING TASK

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.