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OET Letter Case Notes

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OET Letter Case Notes

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      Tina Black

      September 21, 2019

      Your are a nurse at school. Tina Black is a 9 year old primary school student.

      Patient Details

      • Name – Tina Black
      • D.O.B: 9 July 2010
      • Weight 25.8
      • Height: 133 c.m.

      Social History

      • 2 sisters; 1 brother
      • Single mother – Working at a cafe.
      • Poor class attendance
      • Friendly – recently withdrawal
      • Sometimes refuses lunch 

      Past medical history

      • No other illnesses, no allergy
      • 20/8/2019 Vomited at school (ate omelet) Tramadol 37.5, no abdominal pain, no headache. Fluids, rest, sent home
      • 24/8/19 Vomited mid-afternoon (ate omelet for lunch). Fluids, rest, sent home
      • 02/9/19 Vomited, no abdominal pain, slight headache. Called mother, increase frequency – to check the home situation but no answer
      • 18/9/19 Vomited, no pain. Fluid, rest, returned to classes.
      • 23/9/19 Vomited, informed to the mother, unaware.

      Diagnoses

      • Egg allergy
      • Eating disorder

      Plan

      • Watch for allergies; with and without eggs
      • Inform GP
      • Referral to pediatrician

      Task

      Using the information, write a letter to Tina’s GP Dr Green for further investigation and possible referrals to a pediatrician.

      This time the Writing Module was very easy for candidates but the input was too short so many found it hard to reach the word count. Only Listening was tough.

      If you are a tough person and have started preparation for the next exam, you should complete my OET in 30 Days Program.




      Eva Stevenson

      Letter to a Psychiatrist

      Patient Details

      • Eva Stevenson, 31, Armenian
      • Staff nurse, Golden Care Hospital, Star City, Melbourne
      • Visa expires in 2 months
      • Only breadwinner of family
      • Husband Steve unemployed; highly supportive 
      • 2 children. First child is bedridden with down syndrome and breathing problems

      Admission and Discharge Details

      • Admitted on 1st August, 2019
      • Discharged – Today
      • Complaints of trouble in concentrating
      • Feeling worthless, hopeless, depressed
      • Insomnia
      • Loss of appetite
      • Lack of interest in daily life

      Medical history

      • Since 22 July, highly depressed due to repeated failure in OET exams. So far 3 attempts.
      • No history of depression. No family history of depression / suicide attempts
      • In the previous exam (the third) she was highly hopeful – result withheld for a week – she was later informed by Oet that it suspected she had cheated in the exam.
      • Greatly moved by this. Attempted to commit suicide 2 days before admission.
      • Planning to give up OET or any other exam.
      • Her room mate Sylvia reports that Eva was heard shouting in sleep.

      Past Medical History

      • No remarkable medical condition.
      • No previous history of psychiatric illness.
      • Hospitalized due to back pain (2014) and chest congestion (2014).

      Treatment

      • Counselling given. Not cooperative.
      • Learning ability assessed by an English trainer (said she has good learning skills, she has been advised to study under someone who could give her personal care)

      Dietary Habits

      • Eats all cuisines but selectively vegetarian, fast food
      • Never had alcohol in life – but started occasional drinking recently.

      Medication

      • Citalopram 20 mg.
      • Dose can be reduced with reduced symptoms of anxiety.
      • Change to another medicine if nausea, loss of appetite, diarrhea or insomnia noted.

      Management

      • Get a language expert / trainer for her continued training.
        • Work with the trainer / language expert
        • Find out if she has any vital linguistic areas that need to be focused.
        • Work hard with positive thinking
      • Help her to meet those who are in the same situation.
      • Refer the patient to a psychiatrist for:
        • Counselling 
        • Involving a special OET trainer
        • Advise her to try her hand on IELTS or PTE
        • Advise her to study and repeat OET exam.

      Task:

      Write a letter to Mrs Emily Peterson, psychiatrist at Melbourne Mental Care, 6 Russell St, Melbourne 3133, to involve in her case and to do counselling and behavioral therapy along with arranging service of a personal training.




      August 3

      Case note Incomplete

      Patient’s Name – Not Known

      • Letter to a community nurse to request care plan for the patient.

      Admission & Medical history

      • History of Osteoarthritis, DVT, Varicose vein, Dementia and cognitive impairment for long years.
      • Admitted for THR on 11/07/19
      • Developed venous ulcer during second postoperative day at hospital.
      • Dressing, limb elevation, blood thinners, compression sleeves, pain killers, etc provided.

      Today

      • Ulcer has marked improvement.
      • She worries about reoccurrence.

      Purpose

      • Referral to a community nurse to co-ordinate home services.

      Discharge Plan

      • Involve daughter
      • Strict hydration
      • Dressing
      • Compression bandage
      • Leg elevation at rest
      • Co-ordinate activities of podiatrist and physiotherapist.

      Magnus Xavier

      To General Practitioner

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

      Today’s Date 27/06/10

      • You are a Registered Nurse at the Nanango Hospital which is located approximately 200 km north-west of Brisbane, Queensland.
      • Nanango Hospital is a 10-bed acute rural health service with a 24 hours’ primary level emergency department.
      • The hospital is generally staffed by one doctor and ten nurses.
      • On the weekends, there is no doctor and the nursing staff manage all presentations to the hospital, consulting with a medical officer at Kingaroy Hospital by telephone, if necessary.
      • Nurse makes the decision to admit and observe patients or to refer them to other health facilities, if required.

      Magnus Xavier presented to the accident and emergency department yesterday, after having a fall while shopping in Nanango. She was travelling from Murgon to Brisbane with her daughter Cath for NAIDOC week.

      Patient Details

      Name: Magnus Xavier Address: 20 Bunya Street, Murgon Phone: 07 45678910 Date of Birth: 25/03/1967 Marital Status: Widow Next of kin: Daughter Cath; Sons: Vincent and Kevin Ethnicity: Aboriginal

      General Health

      • No known allergies
      • No current medication
      • Weight: 78kg: Height: 161cm; BMI: 30, Waist measurement: 88cm
      • BP 140/85: Pulse 88 • No reported recreational drug use
      • Smokes 15 cigarettes/day • Alcohol use: drinks — 3 standard drinks/night
      • Minimal physical activity

      Medical /Surgical History

      • Had ear infections as a child, treated with antibiotic
      • Had pneumonia 12 months ago
      • Does not know her parents and is not sure about family medical history.
      • Social— husband died two years ago

      26/06/2010

      • Presented to the accident and emergency department following a fall.
      • Did not see step and tripped outside Coles Shopping Centre.
      • No loss of consciousness, did not hit head.
      • Grazed both palms of hands.
      • Felt dizzy after fall.

      On examination: alert and orientated, observations as above.

      • No sutures required.
      • Complaining of pain in foot — both feet examined.
      • Callus on plantar surface of R foot.
      • Ulcer on plantar surface of L foot.
      • Not previously screened for diabetes.
      • In view of risk factors, Random Blood Glucose taken.
      • To stay in hospital overnight for observation.

      Urinalysis

      • tr. Protein 27/06/2010
      • Observations satisfactory overnight.
      • Random Blood Glucose result: 11 mmol/L
      • Needs fasting plasma glucose and /or OGTT
      • Fit for discharge but needs follow-up of possible diabetes.

      Prefers referral to Brisbane Health Service as she will be staying with her Aunty Ruth (Jagara elder), for several months.

      • Risks of smoking and benefits of quitting discussed with patient.
      • Referred to Quit Line

      WRITING TASK

      Write a referral letter to the General Practitioner of the Aboriginal and Torres Strait Islander Community Health Service, 55 Annerley Road, Woolongabba, 4102. Request further investigation for possible type 2 diabetes and for nutrition and podiatry services within the center. Expand on the relevant case notes to explain her background and medical history and the assistance requested.

      • Do not use note form in the letter.




      James Hutton

      Case note 1

      Time allowed: 40 minutes

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

      Today’s date: 10/June/2010

      You are a registered nurse at the Queensland Eye Hospital and you are responsible for the care of Mr James Hutton following the operation he had today (Right Corneal Graft).

      Patient Details

      • Name: James Hutton
      • Address: “Lilyvale”, Mugalala, Queensland, 4461
        Phone: 07 45678910
      • Date of Birth: 25/03/1920
      • Male

      Medical History

      • Blind in left eye following corneal tear in 2001
      • Corneal graft to right eye in 2004
      • Cornea in right eye is now distorted and needs replacement
      • Hypertension diagnosed 2003

      Social History

      • Marital status: Widowed
      • Next of kin: William Hutton (son)
      • Employment: Retired grazier
      • Religion: Church of England
      • Lives in separate accommodation with his son and his family on the family farm.
      • Is generally independent despite limited navigational vision in his right eye and no sight in his left eye.
      • Able to walk without assistance and assist with light work on farm.
      • World War 2 veteran and has a Gold Card which means his expenses for all health care and related transport are paid by the Department of Veterans’ Affairs (DVA).

      Current Medication

      • Atacand 4 mg mane
      • Lipex 10mg nocte
      • Chloromycetin Eye Drops 1 drop in right eye QID
      • Prednefrin Forte Eye Drops 1 drop in right eye QID (Shake well before use and give 1 – 2 minutes after Chloromycetin )
      • Tenopt Eye Drops 1 drop to left eye only BID
      • Panadol 1 gram PRN (Maximum 4 grams per day)

      Nursing care needs

      • Given sedation and local anaesthetic right eye.
      • The local anaesthetic was a full block and he will not be able to open the right eye for several hours. He will be totally without sight until this occurs and should then have restricted vision.
      • A clear eye shield must remain on his right eye at night, to protect from knocks while sleeping. He will need assistance with mobility, showering and dressing.
      • Dark Glasses have been provided by eye hospital to cut down glare when outdoors, if needed.
      • Mr Hutton has an appointment with his eye surgeon at 11am tomorrow. He should be ready for discharge by 10.am when a carer will transport and assist him to the doctor’s surgery.

      WRITING TASK

      The Queensland Eye Hospital provides day surgery only and does not provide over-night care. Patients who need nursing care over-night are sent to a Post -Operative Care Residence. Using the information in the case notes, write a letter to the Registered Nurse at the Post Operative Care Residence explaining Mr Hutton’s condition and the care he will require.

      • Do not use note form in the letter.
      • Expand on the relevant case notes
      • The letter should be 15-20 lines long.
      • No more than the first 25 lines will be assessed.




      Mrs Maria James

      Case note 2

      Writing Time: 45 Minutes

      Read the case notes and complete the writing task which follows:

      CASE NOTES

      Patient details

      • Name : Mrs Maria James
      • Age : 56
      • Address : 956 Addison St, perth
      • Admission  Date : 15/04/2014
      • Discharged Date : 18/04/2014
      • Diagnosis : chronic kidney disease and  bronchial asthma

      Medical History

      Reason for admission:

      • Fever, breathing difficulty for 2 days, tiredness for 1 week, vomiting 5 times.

      Past Medical History

      • Hypertension -2007 (Lisinopril)
      • Diabetes mellitus – 2001(Glyciphage 500mg b d)
      • STEMI – 2005 ( underwent PTCA)
      • Bronchial asthma – Since 2003
      • Osteoarthritis – Since 2007
      • Gastritis – Diagnosed in 2008. Not yet controlled.

      Social History

      • Family – Lives with his husband in a rented house
      • Mother – Hypertension
      • Husband- diabetes mellitus type 2
      • Martha, Her neighbour, is very friendly, visits her in hospital daily.
      • Habit of consuming Alcohol in excess (for the past 20 years)
      • Cigarette smoker

      Medical Management

      • Lasix 100 mg IV Stat
      • Budecort and Duolin Nebulization
      • Oxygen Administration
      • Commenced treatment on Corticosteroids , Immunomodulators and methylxanthines

      On admission,

      • HB – 6 g/dL
      • RBS – 605 mg/dL
      • Urea – 105 mg/dL
      • Creatinine – 5.4 mg/dL
      • Calcium-6 mg/dL
      • Phosphorus- 10mg/dL
      • Potassium – 9mEq/L
      • X Ray – Pulmonary Edema
      • Total cholesterol – 225 mg/dL
      • CBC : 6500 mL

      Nursing management

      • Vital signs: BP – 200/100 mm og Hg, pulse 120/ mnt, respiration – 26/ mnt, temp – 100
      • 2 unit packed cell transfused
      • High Fowler’s Position recommended
      • Chest physiotherapy and deep breathing exercises

      16/04/2014 Assessment

      • Bp – 180/100 mm of hg , pulse – 100 , respiration – 24, temp – 99
      • Pedal edema 3+
      • Weight : 51kg
      • Abdomen was protuberant
      • Shortness of breath
      • Advised chest physiotherapy and deep breathing exercises

      17/04/2014 Assessment

      • Bp – 190/100 mm of hg, pulse – 105 , respiration – 22, temp- 99
      • Breathing difficulty and advised to provide high fowler’s position with oxygen therapy
      • Oliguria
      • Efcorlin 100 mg
      • Lasix 40 mg
      • Gained 2 kg body weight
      • Bowel pattern impaired. Now treated with laxatives.

      18/042014 Assessment

      • Bp – 200/100 mm of hg; Pulse – 100; Respiration – 20; Temp – 99
      • Weight : 54kg
      • Pitting edema 4+ (Pedal Oedema)
      • Oliguria
      • Melena
      • Need to continue same antihypertensive drugs and hypoglycaemic agents.
      • Stool occult blood positive
      • HB-7.2g/dL
      • RBS-510mg/dL
      • Creatinine – 5.2 mg/dL
      • Potassium – 8mEq/L
      • 1 unit packed cell transfused
      • Discharge from the hospital

      TASK

      Using the information given in the case notes, write a referral letter to the nephrologist, Dr Abraham John, Hyde hospital, Adelaide St. Perth.

      In your answer, expand the relevant case notes into complete sentence.




      Ryan and Rohan

      Case note 3

      WRITING SUB TEST       NURSING

      TIME ALLOWED              READING TIME 5 MINUTES
      WRITING TIME 40 MINUTES

      NOTES:

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

      Ryan and Rohan are patients in a new-born ICU where you are the NICU charge nurse at Royal Woman’s Hospital, Sydney. Mother is already discharged and babies are yet to be discharged.

      Age                                       1 week old babies.
      Address                               1278 Over the Avenue
      Victoria, Sydney 0099
      Mother                                Mrs Angelina Mickle, DOB 19/10/1995
      Had gestational diabetes mellitus during antenatal period.
      Attended all antenatal visits.

      Father: Mickle Luke, 34 years, graphic designer.

      Other children                   Reyona Mickle, 2 years

      Medical History                 Mrs Mickle’s admission date – 08.01.2019;

      • Complained of foetal distress due to cord entanglement;
      • Caesarean section done at midnight, day of admission.

      Patient 1 Details – Ryan, 3 days, first baby

      • Aspirated meconium
      • ↓ HR, ↑ RR, bluish discoloration on upper and lower extremities;
      • Apgar 4/10, poor sucking O2 2L/hr
      • Weight: 2.5 kg
      • Fraternal twins (dizygotic)
      • Diagnosis confirmed through chest X-ray and blood gas test.
      • Medical progress – 17.01.19 Poor sucking.

      Nursing management   

      • Prophylactic antibiotic therapy,
      • Ampicillin 50 mg BD, Gentamycin 15 mg BD
      • Radiant warmer therapy
      • IV Fluid DNS
      • Oxygen therapy (via tent)
      • CPAP for 3 days after delivery

      Patient 2 Details – Rohan, 3 days, second baby

      • Weight: 2 kg at the time of birth
      • Poor sucking, Apgar 6/10, HR good, ↓RR
      • Both are expelled meconium.

      Diagnosis

      • Cleft lip and cleft palate;
      • Mother depressed.

      Nursing Management

      • IVF DNS therapy
      • Oxygen therapy (via tent)
      • Radiant warmer therapy to continue till he gains weight.

      General Discharge Plan

      • Roshan needs radiant warmer therapy;
      • Monitor sucking ability of both children;
      • Continue IVF therapy (both children);
      • Roshan needs paediatric surgical consultation.
      • Monitor their weight everyday;
      • Needs psychological support for their family especially for their mother.

      Writing Task

      Using the information given in the case notes, write a referral letter to MS Daniela Robertson, New-born Specialist Nurse, Sydney Children’s Hospital, Randwick NSW, Australia. Inform her of the current situation, medical background of the new born babies and requesting an immediate management for both babies.




      Ms Syndrella Picher

      Case note 4

      Time allowed: 40 minutes

      Notes:

      Ms Syndrella Picher is a patient in your care at the Kilda Station Women’s Refuge Centre. She is 6 weeks pregnant with her first child. She presented two days ago, requesting help for her substance abuse problems. She reports a desire to reduce or cease her alcohol consumption and a desire to reduce a cease her drug use. No desire has been indicated to decrease or stop
      cigarette use. She now wishes to be discharged but will require ongoing support throughout her pregnancy.

      Discharge summary:

      • Name: Ms Syndrella Picher
      • Age: 23
      • Admission: 6/1/2019
      • Diagnosis: pregnant substance abuse
      • Discharge: 8/1/2019

      Plan:

      • Community mental Health Nursing required daily next 2 weeks minimum.
      • Pt wishes to continue living with a friend on her sofa.
      • Psychiatric support needed for depression.
      • Methadone program Alcoholics Anonymous meetings
      • 1 Trimester Ultrasound at 2 weeks;
      • Maternal health clinic appointment needed.

      Reason for admission:

      • Pt. self admitted due to concern about pregnancy. Confirmed pregnancy test the days before (5/1/09)
      • Reported pain in lower back
      • Weight loss (6kg over 2 months)
      • Some memory loss
      • Tingling in feet, difficulty sleeping, excessive worry and hallucinations
      • Feeling depressed-history of depression
      • No pain in hips or joints
      • No decrease in appetite
      • No double vision

      Treatment

      • Pt. monitored and blood tests for HIV/AIDS and STDs
      • Counseled re nutrition and pregnancy
      • Counseled re HIV/AIDS and STDs risk
      • Discussed possibility of rehabilitation clinic for ‘driving out’

      Lifestyle

      • Nicotine daily 30-40 cigarettes
      • Started smoking at 15 y. o.
      • Drugs used cannabis, amphetamines, cocaine, heroin
      • Started all above at 16 y. o.
      • Injects heroin, occasionally shares infecting equipment
      • Alcohol 8 units/day __ max. units/day- 15
      • Started drinking at 16 y. o.
      • Lives with a friend, Sophie, on her sofa.
      • No contact with parents.

      History

      • Suicidal thoughts, self harm in past
      • Never seen a psychiatrist

      Writing Task

      Using the notes, write a letter about Ms Picher situation and history to new community health nurse. Address your letter to Ms. Lucy Tan, Registered Nurse, Community Health Centre, Kilda Station.




      Biju John

      Love for English begins with understanding its unknown rules. Biju John lives on the internet, teaching OET, IELTS and PTE. More than a million students have thanked him from their heart.

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