Case Notes 4

Occupational English Test – Writing (Nursing)

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

Notes:  

Assume that today’s date is 6 March, 2024. You are Miss Fiona Carwell’s School Health Nurse and the patient is attending 6th grade at your school. 

Patient Details:

• Name: Fiona Carwell.
• DOB: 06 Dec 2011 (12 y.o.)
• Address: 32 Station Road, Oakville

Social background:

• She’s from a migrant family from Spain relocated to Oakville, 1999.
• Father’s demise, June 2023, (MVA).
• Family reports grief. Pt reports extreme stress re. worries about the future in the absence of father who was really close with her. 
• BMI 29 (recently gained weight due to poor diet control).
• Older brother-mental health problems (2 suicide attempts in last 12 months).

Medical History

08 July, 2023, 0915 hrs

• Feeling very thirsty.
• Passing urine more often than usual, particularly at night.
• Feeling very tired all the time; Weight loss of 6 kg in 2 months.
• Frequent oral thrush. Blurred vision.
• Emergency hospital admission (Oakville General Hospital) following an episode of LOC.
• Lab Investigations: Random Blood Sugar of 11.9 mmol/L. HbA1C high.
• Diagnosis: type 1 DM. Treatment: Novolin N 4 Unit at tarde; Solostar 8 unit at nocte.
• Discharge Date: 15 July, 2023.

Discharge Recommendations:

• Dietician referral.
• Lifestyle management.
• Diabetes Nurse Specialist referral at Oakville General Hospital for follow up care (diet, insulin).
• Review at DNS.

11 August, 2023

• Well maintained Blood Sugar.
• Following healthy lifestyle along with proper nutrition (well-balanced calorie diet). RBS 4.6. Reduced Solostar to 6 unit due to several hypo attacks at night.

18 December, 2023

• Blurred vision. Increased power.
• S/B ophthalmologist.
• Started to wear spectacles. 
• Reduced symptoms.
• No headache or Blurred vision (thereafter).

6 March, 2024

• Dizziness and light-headedness, sleepy during class.
• Pt reports stress due to grief.
• Pt reports stress induced overeating
• Management: RBS 16.8, urine ketones high. Blood ketones 0.9

Plan: 

• Referral to Diabetes Nurse Specialist.
• Review of meds.
• Discuss ways to encourage lifestyle changes.
• Plan further management.

Writing Task

Using the information given in the case notes, write a letter of referral to Ms Catherine Flanagan, Diabetes Nurse Specialist, Oakville General Hospital. In your letter, briefly outline Ms Carwell’s recent history requesting advice and a review of her medication.

In your answer:

• Expand the relevant notes into complete sentences.
• Do not use note form.
• Use letter format.