Case Notes 8 – Michael Chan
Occupational English Test – Writing case Notes | Nursing
Read the case notes below and complete the writing task which follows.
Notes:
Today’s date is 27th May, 2024. You are a nurse working at Sydney Central Hospital and this patient is under your care.
- Name: Mr. Michael Chan.
- Age: 33 years.
- Occupation: Film actor and Producer.
- Patient’s Home Address: 456 Elm Street, Sydney, NSW 2000.
12 January, 2023
- Visited his new GP, Dr Sen Hendrik, at Wellness Hospital, Perth with complaints of shortness of breath and poor appetite.
- BP and Sugars normal. ? multiple health issues.
- Commenced multivitamins, advised rest and smoking cessation.
18 January, 2024
- Reviewed with GP.
- The GP observed that the patient did not follow her advice. Mr Chan explained that he honestly did not have trust in the GP’s expertise and knowledge. Tensions high between the doctor and patient.
26 April, 2024
- Admitted to Sydney Central Hospital (his new film was being shot there).
- Same complaints. Diagnosed: Hypoxia and Hypothermia.
- Cordarone, 800 mg commenced (for three weeks).
- Corticosteroids. Oxygen therapy for three days.
- Discharged.
27 May, 2024
- Worsening Hypoxia and hypothermia.
- ?Onset of anorexia and insomnia.
Lifestyle Factors:
- Smoker (more than 5 packets per day).
- Drinks socially.
- BMI: 31
Personal Information:
- Last five movies flopped at the box office.
- Experiencing heavy financial losses and liabilities.
- Married to Mary Izabelle, 26 years old.
- Expecting their first baby in a month.
Current Medications:
- Oxygen Therapy: 2 litres per minute via nasal cannula, continuous.
- Multivitamins: Once daily.
- Cordarone, 1200 mg.
- Appetite Stimulant (Megestrol acetate): 400 mg orally once daily.
- Anti-anxiety Medication (Diazepam): 5 mg orally twice daily as needed
Discharge Plan:
- Follow-up Appointment: Schedule a follow-up visit with the primary care physician in one week.
- Referral to pulmonologist for further assessment of hypoxia.
- Referral to nutritionist for diet and weight management.
- Referral to Mental health professional for stress and anxiety management.
- Smoking Cessation Support: Enrol in a smoking cessation program to reduce and eventually quit smoking.
- Alcohol Consumption: Advice to limit social drinking to moderate levels and discuss potential support if needed.
- Educate Mr. Chan about the signs and symptoms of worsening hypoxia and hypothermia, and when to seek immediate medical attention.
- Provide information on healthy lifestyle choices to improve overall well-being and manage stress.
- Monitor for compliance with medication and lifestyle changes.
- Reinforce the importance of follow-up visits and adherence to the discharge plan.
Dietary Recommendations given to the patient:
- Encourage small, frequent, high-calorie meals to address anorexia.
- Include protein-rich and nutrient-dense foods.
- Hydration: Ensure adequate fluid intake to prevent dehydration.
Rest and Recovery (Nursing Management):
- Encouraged adequate rest and stress reduction techniques. Patient is taking a week’s break from all activities from tonight.
- Suggested relaxation exercises and mindfulness practices. Patient is compliant.
- Family Support: Discussed with Mr. Chan the importance of family support during this time, particularly with the upcoming birth of his child.
Writing Task
Using the information in the case notes, write a letter to Dr Mona Hendrik, GP, Sydney Hospital for Mr Chan’s hypoxia and hypothermia management. Address the letter to Dr Mona Hendrik, 123 Harbour Street, Sydney, NSW 2000.
In your answer:
- Expand the relevant notes into complete sentences.
- Do not use note form.
- Use letter format
The body of the letter should be approximately 180–200 words.
Letter
27th May, 2024
Dr Mona Hendrik
Sydney Hospital
123 Harbour Street
Sydney, NSW 2000
Dear Doctor,
Re: Mr. Michael Chan; 33 years old
Mr Michael Chan requires management of hypoxia and hypothermia. He also has suspected onset of anorexia and insomnia.
On 26 April, Mr Chan was admitted to Sydney Central Hospital. He was diagnosed with hypoxia and hypothermia. His treatment commenced on Cordarone, 800 mg., for three weeks, and Corticosteroids along with oxygen therapy for three days.
Today, Mr Chan visited with worsening Hypoxia and hypothermia. Based on investigations, he has been suspected with an onset of anorexia and insomnia.
Mr Chan smokes more than 5 packets per day. A film producer, he is experiencing heavy financial losses and liabilities due to loss in business. Please note, his BMI is 31.
Based on Mr Chan’s present condition, referrals to a pulmonologist, a nutritionist and another referral to Mental health professional for stress and anxiety management have been scheduled. It is important to enrol him in a smoking cessation program to reduce and eventually quit smoking. Mr Chan will greatly benefit from education about the signs and symptoms of worsening hypoxia and hypothermia, and when to seek immediate medical attention. He needs to be monitored for compliance with medication and lifestyle changes. Kindly reinforce the importance of follow-up visits and adherence to the discharge plan since he has been averse to follow ups.
For any further information, kindly contact me.
Yours faithfully,
Charge Nurse
Sydney Central Hospital.
