Case Notes – Timothy Lawrence

Case Notes: Mr Timothy Lawrence

WRITNG SUB-TEST: NURSING
TIME ALLOWED: READING TIME: 5 MINUTES

WRITING TIME: 45 MINUTES

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

• Assume that today’s date is 10/04/2023

NOTES:

• Name: Mr. Timothy Lawrence (Mr)
• Date of Birth: 3 May 1953
• Address: 01 Red Stones, Greenville; Phone: Not available

Social history:

• Lives with wife and daughter in law
• Retired officer. Did managerial works
• No alcohol
• Smokes 25 cigarettes per day
• Weight 105kg

Medical history:

• 2017-Hypertension on ramipril
• Osteoarthritis (knee) (2015) (hip) (2018)
• Overweight – counselled for weight reducing exercise

Presenting complaint (05/04/2023)

• Fall at home
• Altered sensation and confusion
• Weakness on upper and lower limbs
• Right side weakness (arm and leg)
• Facial droop

Assessment:

• BP 205/105
• Pulse irregular
• Saturation 90

Physical examination:

• Weakness on muscle
• ? disorientation left side

Investigation:

• Blood test and ECG normal
• CT shows bleeding – atherosclerosis, low blood flow
• Ischemic stroke, diagnosed

07/04/2023

• Reductant to move (pain), use walker frame
• Pressure ulcer on left hip (on hydrocolloid dressing)
• Urinary tract infection (on antibiotics)
• Health education regarding diet, exercise and smoking

Discharge Date: 17/04/2023

Plan:

• Monitor medication compliance
• Community nurse – change dressing twice weekly
• Monitor UTI symptoms with midstream urine after antibiotic completion

WRITING TASK:

Using the information in the case notes, write a letter to the community health nurse for continued care of patient at home. Address the letter to community health nurse, district nursing service, Greenville community health care center, 88 Highton Road Greenville

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.

Letter Completion

10th April, 2023

The Community Health Nurse
District Nursing Service
Greenville Community Health Care Centre
88 Highton Road, Greenville

Dear Nurse,

Re: Mr Timothy Lawrence; DOB: 3 May, 1953

Mr (1) ____ (Timothy Lawrence / Lawrence) requires (2) ____ (continuous / continued) care and monitoring (3) _____ (followed by / following) his (4) _____ (discharged / discharge) after (5) ____ (a / one) week. He is recuperating (6) ____ (from / after) pressure ulcers on (7) ____ (the left hip / left hip).

Mr Lawrence (8) ______ (was presented / was admitted / presented) on 05 April, 2023 with (9) ____ (alter / altered) sensation, (10) ____ (confused / confusion), right-sided weakness, left-sided disorientation (11) _____ (besides / and) facial drop. He (12) ____ (has been / was) diagnosed (13) ____ (as / with) ischemic stroke and urinary tract infection based on the radiological and blood examinations. Therefore, he has to be done midstream urine after (14) antibiotic completion à completing the course of antibiotics and (15) monitor the symptoms à monitoring the symptoms. He has hydrocolloid dressing on pressure ulcer which (16) needs to continue to change à need to be changed thrice weekly.

The last two sentences of the paragraph above are not required there. You can see that they are “requests” which is found in the last paragraph, only.

A retired manager, Mr Lawrence (17) ____ (is living / lives) with wife and daughter-in-law. He (18) ____ (was / has been) (19) _____ (hypertension / hypertensive) since 2017 and takes ramipril. He smokes (20) around /approximately 25 cigarettes daily and his weight is 105 kgs. He (21) ____ (has been / was) educated about smoking and diet. In addition, he (22) ____ (has been / has / was) counselled (23) ____ (for / about) weight reducing exercises.

(24) _____ (I / It) would be appreciated if you (25) ____ (can / could) (26) _____ (visit / visited) Mr Lawrence at his home and monitor his medication compliance (27) which will help him (28) _____ (with / for) his speedy recovery.

NB: The last part of the last sentence above is not really required. Why? The recipient also knows that “speedy recovery” is the aim of writing this letter. Does any nurse wish that the patient recovers slowly?

If you (29) ____ (need / have) any (30) ____ (further / x) queries, please do not hesitate to contact me.

Yours faithfully,

Charge Nurse.