Occupational English Test – Writing case Notes | Nursing
Read the case notes below and complete the writing task which follows.
Notes:
Today’s Date: 27 March, 2024
You are Lee Wong, a registered nurse in the Coronary Care Unit, St Andrews Hospital, Brisbane. This patient is in your care.
Patient Details
- Name: Noah M Caprio (Mr).
- DOB 12 January 1959.
- Address: 9476 Old Dam Road, Woodwind Q4390.
- Next of Kin: Brother, Ernie Oriel 72. Bedford St, Jericho, Q4490.
- Admitted 20 March, 2024.
- Diagnosis: Obstructive coronary artery disease.
- Operation Coronary artery bypass grafts (x 4) on 22 March, 2024
LONS (Lifestyle, Occupation, Nutrition, Social) History
- Never married. Lives alone in own home just outside Woodwind.
- Fencing contractor.
- Skips breakfast. Heavy meaty meals for the last three years.
- Smokes 20 cigarettes/day.
- Smoked 40+ cigarettes / day till 2022.
- Chain-smoker till 2020.
- Consumed processed fish in large quantities in the last three months.
- Alcohol: 2 x 300 ml bottles beer / day.
- Usual diet: Sausages, deep fried chips, eggs, MacDonald’s;
Medical History
- Ht 170cm; Wt 99kg. Allergic reaction to nuts.
- ? Abdominal Aortic Aneurysm (2022); No follow up. Symptoms ruled out by GP (2024, February)
Nursing Management and Progress
- Routine post-operative recovery slow.
- Advised to cease smoking, reduce alcohol.
- Patient not willing to cease smoking. Says, “it kills.”
- Has considerably reduced drinking.
- Commenced a low fat diet recently but failed to cope.
- Walking well. Wounds healing well.
- Routine visit from Social Worker for the last three days.
Discharge Plan
- Going to Jericho on day fifth from discharge to stay with brother.
- Appointment made for follow up visit to local GP Dr. Avril Jensen 2 pm 31 March, 2024.
- Local physiotherapist to continue rehabilitation exercise program for five days.
- Arrange meeting with Mr Steeth Singh, Tobacco Cessation Specialist, at his clinic, Jericho: Phone 666773434.
Writing Task
Write a letter to Mr Steeth Singh, Tobacco cessation Specialist, Gregory Terrace, Jericho. Use the relevant case notes to explain Mr Di Caprio’s situation. Include Medical History, Body Mass Index and lifestyle along with a detailed smoking history.
In your answer:
- Expand the relevant case notes into complete sentences.
- Do not use note form.
- Use the correct letter format.
The body of your letter should be approximately 200 words.
