Case Notes 7

Occupational English Test – Writing case Notes | Nursing

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

Notes:

You are a registered nurse in the Coronary Care Unit, St. John’s Hospital, London. Jamie Morgan is a patient in your care. 

• Today’s Date: 04/03/2024

Patient Details

• Name: Jamie Morgan.
• DOB: 22 February 1967.
• Address 9476 Old Dam Road, Barona, London.
• Next of Kin Brother, Justin Morgan 72, Burke St, Old Ormond Street, Queensland, Australia.
• Admitted: 28/02/2024
• Diagnosis: Obstructive Coronary Artery Disease 
• First treatment planned: CABG.
• Treatment Provided (due to fear of complications): Percutaneous Coronary Intervention (29/02/2024).

Social History 

• Never married.
• Lives alone in own home at Barona, London.
• Computer trainer, Android app developer.

Medical History 

• Smoked 30 cigarettes/day until admission.
• Has been compliant to sudden smoking cessation.
• Alcohol: 3 x 300 ml bottles beer / day, till admission date.
• Ht. 177 cm; Wt. 96 kg (stable for the last 15 years).
• Usual diet: Sausages, deep fried chips, burgers, eggs, MacDonald’s.
• Allergic reaction to peanuts.

Nursing Management and Progress 

01/03/2024

• Routine postoperative recovery but slow.
• Smoking nil, alcohol nil.
• Low fat diet.
• Walking with a little limping.
• Wounds healing.
• Routine visit from Social Worker, Physiotherapist.

03/03/2024

• ? Mild injury to the heart arteries, including tears / rupture.
• No infection, bleeding, or bruising at the catheter site.
• No allergic reaction to dye.
• No kidney damage (from the dye or contrast).
• Blood clots suspected.
• Patient not in critical condition; Can travel.
• Current Medicines: Clopidogrel 75 mg BD increased to 300 mg nightly.

Plan 

• Returning Home to Barona and then moving to Australia to stay with Mr Justine Morgan on 07/03/2024.
• Appointment made for follow up visit to Dr Sigmund Steve, 02 pm on 11/03/2024 at the doctor’s clinic.
• Local physiotherapist to continue rehabilitation exercise program till departure to Australia.

Writing Task

Using the information in the case notes, write a letter to Dr Sigmund Steve, Cardiovascular Surgeon at Caredio, New Ormond Street, Queensland, Australia. In your letter, list out Mr Morgan’s recent medical history and discharge plan.

In your answer: 

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