Welcome to Day 12!
Your skill to expand notes is very important. At times there are notes as short as two words, like, “being discharged” or two pieces of sentences, like, “completely dependent – needs assistance.” In both cases, an OETian should be good at expanding – not too long, not too short. In simple words, if there are five words in the notes, try to expand to 15 or 20 words.
Below you will see a large number of common notes and their expanded form. Learn each line and improve your skill
Expanding little lines and short phrases into perfect, full-fledged sentences is another task that an OETian has to successfully carry out. While expanding notes, you will see a few questions like these arise:
- How much to expand?
- What should be expanded?
- What should not be expanded.
Suppose you are writing to a patient’s family doctor, how much should be told to the doctor? Certainly we do not have to write all the past history of the patient as the doctor is aware of the patient’s medical history.
How to Expand?
The notes contain a word or two so you have to add all the missing words. In most cases, notes come without articles (a, an, the), prepositions (in, on, out, by, from, etc.), connectors (besides, additionally, also, however, but, etc.). You need to add them all, wherever required.
Be sure you do not use too many connectors and prepositions.
Admitted with pneumonia.
The patient was admitted to this hospital with definitive symptoms of pneumonia.
Acute shortness of breath (SoB).
On examination, it was found out that the patient had acute shortness of breath.
Inspiratory and expiratory wheezing.
Further investigations revealed that the patient had wheezing – inspiratory and expiratory.
Patient : Nimmy Isaac.
I am writing to refer Ms Nimmy Isaac…
Patient’s name – Mr Evans Roderick
May I refer Mr Evans Roderick to your facility…
72 year old – Married woman
Ms. Isaac is a 72 year old married woman.
Open heart surgery patient
This is important to note that the patient has had an open heart surgery recently.
Chronic Obstructive Pulmonary Disease, Anxiety
Besides, the patient is a known case of chronic obstructive pulmonary disease.
Lives at home with husband, Isaac.
Ms Nimmy lives at her home with her husband.
Married 50 years.
The two have been married for fifty years.
Isaac – decorated soldier – fought in World War II.
This may be noted that Mr. Isaac is a decorated soldier who had fought in the World War II.
Isaac attends RSL meetings and enjoys the camaraderie.
Besides, Mr. Isaac attends RSL (Returned Soldiers’ League) meetings and enjoys the camaraderie
Faced CVA 2 years ago
Mr Mabel suffered Cerebrovascular Accident (CVA) some 2 years ago.
Agile, mentally active, speech slightly slurred.
Although Mr. Mabel is agile and mentally active, his speech has been found slightly slurred.
Complaining of severe illness.
Apart from this, he has, on several occasions, complained of severe illness.
Walks with limp – impaired balance.
It is important to note that the patient walks with a limp, possibly because of his impaired balance.
Fell off the stair – badly injured right knee.
Later he fell off the stair from a considerable height and badly injured his right knee.
GP requested ‘Your Health Care Agency’ for dressing and assisting in taking shower daily.
Now, the GP has requested the assistance of Your Health Care Agency for dressing and assisting in taking shower daily.
Smoked for 40 years – gave away in 2004.
Looking at her family history, Ms. Isaac smoked for 40 years. However, she gave it up in 2014.
Mother overweight – high BP.
Mother died of Myocardial infarction at age 75 (20 years ago)
This is also to be noted that her mother was overweight with high BP and died of myocardial infarction at the age of 75.
Admitted: 10 days ago for a double by pass. All went well. Has been recuperating.
Ms. Isaac had been admitted 10 days ago for a double bypass surgery and is recuperating post-operatively.
The patient is suffering from severe anxiety.
Not sure how she is going to cope after discharge..
Therefore it cannot be assessed how the client is going to cope with her anxiety after discharge.
Worried she will die like her mother.
Probably she fears that she would meet with an unexpected and premature death like her mother.
Please note that the patient shows such symptoms that she is visibly distressed.
Has outbursts of crying.
It has been noticed that the patient is habitual to frequent outbursts of crying.
Regular absence from school – father’s death.
She has been regularly absent from school dating back to the time of his father’s death.
Has been using an oxygen concentrator;
Since then she has been using an oxygen concentrator to avoid any chances of misadventure.
To be issued with a rented portable oxygen concentrator on discharge.
The hospital shall issue a rented portable oxygen concentrator for the patient’s use on these fifty days.
Prescribed Lipotor Oral, using Ventolin when required;
Apart from Lipotor oral, the doctor has prescribed Ventolin as per requirement.
Taught postural drainage position and pursed lip breathing technique.
Apart from the above mentioned awareness programs, the patient has been taught postural drainage position pursed lip breathing techniques.
Advised to quit smoking – Pt refusing.
In spite of the patient’s refusal, he has been advised to quit smoking during the course of medication.
Prescribed Nicorette patches.
Her doctor has prescribed Nicorette patches for improving nocotine level in her body.
To be discharged tomorrow.
May I bring to your immediate notice that the patient is due to be discharged tomorrow.
How to expand notes?
- For this patient maintain overall life style plan.
- Diagnosed with type 2 diabetes August. 2016.
- GP recommended dietary management low fat, sugar, salt, limit alcohol.
- Pt lives at home with wife.
- Wife cooks and managing dietary requirements.
- December 2017: Wife deceased, pt depressed.
- Or non-compliant with diet.
- Excessive fat, salt, sugar, alcohol.
- Go prescribed Metformin.
- Now pt cooking for self non-compliant with diet, medication.
- Blames poor memory
- Pt appears unmotivated.
- Resents having to take medication, “always been healthy”
- Takes medications intermittently.
- June 2018 – Pt hospitalized with MI.
- October 2018 – Pt now walking with a stick – Signs of diabetic neuropathy – Non-compliance with diet continues – pt attended with daughter.
Setting – A Medical Centre
You are speaking to Margaret, a patient who needs to start chemotherapy.
Explain what chemotherapy is and the treatment process. Discuss the side effects including fatigue, nausea and vomitting, mouth ulcers and hair loss, and talk to your patient about coping with them.
Talk to your patient about life during treatment including the possibility of continuing with regular exercise.
Setting – A Medical Centre
You are Margaret, a 51 year old teacher. You are married and have two teenage children. Your husband also works full time. You have been diagnosed with cancer, and have been told that you will be having a course of chemotherapy starting next week.
You feel very upset and shocked about your diagnosis, but have determined to find out as much as possible about the treatment and how it is going to affect you. You really don’t know what is involved with chemotherapy. Find out about the treatment and side effects. you are a fit and healthy woman and enjoy a daily exercise program. Find out if this is going to be affected.
Setting – Private Clinic
You are a 52 year old working long hours in customer service. You are tired and have beeen experiencing aching feet. Sometimes you have numbness and tingling, which is worse at night. You are worried because your uncle has Multiple Sclerosisand your aunt has Parkinson’s disease.
Tell the nurse that you are very tired, you suffer from symptoms in the feet, your memory is not too good and when you are stressed your hands shake.
Explain that your work is stressful, moves at a frantic pace and you have dozens of things to remember, but don’t write them down. What can be done?
Accept that perhaps stress is causing your symptoms.
Agree to a referral to a podiatrist and seek advice from a doctor.
Reluctantly express the ‘real’ reason you are here – you are extremly ‘paranoid’ about the chance that may have a neurological disease because of your family history.
Setting – Private Clinic
You are attending to a 52 year old who works long hours in customeer service. The patient complains of being tired and has been experiencing aching feet. sometimes he/she has numbness and tingling, which is worse at night. The patient admits to being ‘paranoid’ as the uncle has Multiple Sclerosis and the aunt has Parkinson’s disease
Explain that working long hours and stress may produce symptoms such as tiredness and poor memory.
Suggest initial steps to improve sore feet issues (comfortable shoes, orthopedic shoes, compression stockings etc).
Emphasise that you think the patient may be putting too much pressure on him/herself.
Explain that you will examine the feet for obvious signs of injury and suggest a visit to a podiatrist.
Advise the patient to arrange a medical appointment.
Highlight the importance of not self-diagnosing and thinking the worst.
Patient - Wayne Tucker
Marital Status: Unmarried
This letter calls your attention to a little complicated case of Mr Wayne Tucker who was admitted to our care on 4th September, 2016 with severe occipital headache associated with unstable gait and dizziness.
Thank you for accepting the aforementioned bachelor who requires continuity of care from your service . He underwent craniotomy in view of his cystic mass lesion and is recuperating well.
One of his neighbors admitted him into the hospital after he had been complaining of severe headache. The patient was swaying to both sides while walking due to extreme headaches and dizziness/vertigo.
On his admission assisted by his neighbors, Mr Tucker was found swaying to both sides while walking. It was soon found out that the patient’s irregular movement was caused by headache and dizziness.
Occipital headache (for the last 1 year, August 2015 – August 2016)
CT scan (taken after one month) doesn’t show any presence of residual lesion.
The condition of the patient was normal at the time of discharge. Recommended to contact Dr. Tiana for further treatment.
In the light of the above, it would be greatly appreciated if you could examine Mr Tucker and manage his condition as deemed appropriate. All pertinent documents obtained during his confinement is enclosed.
Lives alone in an apartment (Kiol Apartment, 5/11 Stratfield Square, Sydney NSW 2136, Australia)
It may be of note that he lives on his own.