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Case Notes Creation Task

Today you are not writing a letter from a case-notes – but building one yourselves!

When you build a question, your learning becomes easier!

How to Build a Case Notes?

  1. Imagine a patient / more patients in your care. His / her name, age, address.
  2. Imagine a recipient (any medical staff, carer, relative)
  3. What is the patient’s presenting condition, present condition.
  4. Do not forget a past medical history of the patient.
  5. Include a family history.
  6. What has your hospital done for the patient so far.
  7. What is treatment / management plan for the patient?
  8. What is the purpose of writing this letter? The candidate should be confused.
  9. Try to include multiple purposes and multiple patients.
  10. Make sure you include admission date and discharge dates but you can confuse the candidate.
  11. Include at least 10% irrelevant information that the recipient will not require.
  12. Mention some social background of the patient.
  13. Is the patient going to have follow-up visits?
  14. Use “banned” words in the case notes so that the OET candidate will be tempted to use them.
  15. Include something very tricky (the OET candidate should think it is relevant)

Now, proceed to building your case-notes. Write your case notes in the Comments box below!

Written by 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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5 Comments

  1. Name :Mr Christopher
    Age;49years
    Married, lives with wife and 2 children
    Admission date :20/2/2020
    Presented with -chestpain,radiating to shoulder, difficult breathing -2days along with generalised weakness, nausea , dizziness.
    Ecg-ST elevation
    Ckmb+
    Diagnosis -Myocardial infarction

    Medicalhistory:

    Peptic ulcer disease
    Twice clipping done
    Hypertension-8years, on tab Nicardia 5mg once daily
    Diabetic -9years , Human mixtrad Bd
    Heavy drinker and smoker since 10years
    Eats oilyfoods, and sugary creams
    No exercise

    Nursing Mangaement and progress:

    Height :173cm
    Weight 59kg
    Tem:98.6°F
    Pulse :72b/m
    Res:14b/m
    Blood pressure:150/100mmofhg

    Medications

    Pan 40 mg BD for one month
    Aspirin 325mg one month
    Statix 40mg of one month
    Paraffin 10mg of one month
    Investigations Report:

    RBS:190mg/dl
    FBS:118mg/dl
    LDL:120mg/dl
    HDL:40mg/dl
    HB:, 12

    21/2/2020
    Angiogram:

    Presnce of clots in the left side of the coronary artery.
    Percutaneous tranluminal coronary angioplasty done.

    Post -operative progress:
    No complications
    Blood pressure and blood sugar under control
    R/W dietician Recommended_Avoid oily foods and carbohydrates
    Increase green leafy veggies, fruits and vegetables,
    Fluid intake

    He is ready to be discharged after the consultation with consultant.

    Discharge plan:

    Kindly schedule a follow up with Fbs, FLP, reports on 3/3/2020.
    Medication monitoring
    Quitline programs
    Blood pressure and blood sugar monitoring
    Dietary management
    Encourage daily Exercise
    Follow up
    Avoid sternous exceises for two weeks.

    Using the given information Write a letter to The district nurse requesting home visits to ensure medication compliance and dietary restrictions

  2. You are a nurse in a pediatric ward of St Charles Children’s Hospital

    Patient name: Tant Sona
    Age: 2 years
    Admitted on 20/10/2019
    Discharged on 25/10/2019
    Address: 23, Monalisa Street, Lagos Nigeria
    Mother: 20 year old unemployed school leaver

    history
    Coughs, catarrh, weakness, fever, shortness of breath, unkept, malnourished, weighed below her age, sunken eye and dry skin

    Lives with mother in an uncompleted building, father rejected his pregnancy. No relatives around

    Mother was referred to social worker

    Treated with antibiotics, inhaler and hot water steaming
    Nutritional needs met while on admission

    Child is okay now, eating well and running around

    Discharge plan

    Teach mother how to prepare nutritious meal, child to continue antibiotics and vitamin c for the next seven days, follow-up clinic on 1/11/2019

    Write a letter to the Nutrition Department of
    St. Charles Children’s Hospital, highlighting the patient’s nutritional needs

  3. Patient name. John Markose
    Age 55
    Lives alone, wife dead 2 yrs back, 1 son settled in Newsland.
    Admission date 10/6/2020
    Discharge date 15/6/2020
    Reason for admission. Fatigue, severe abdominal pain, fever&vomiting.
    Emergency USG performed-ruptured appendix with fluid filled abdomen.
    Laparoscopy+abdominal drainge. 300ml fluid drained.
    Nursing management:
    Iv fluids
    Antibiotics
    Post op day 3
    Patient complaint severe pain &weakness
    Morphine given, Iv fuids

    Allergies:egg and nuts
    Smokes 20 cigarette per day, occational drinker, sedentary lifestyle.
    Made significant improvement
    Ready for discharge.
    Discharge plan:
    2 wks rest
    Antibiotics and pain killers
    Follow up visit after 2 wks
    Arranged meals on wheals

    Writing task. Using the information write a letter to district nurse and request homevisits for further care and assistance.

  4. Patient name. John Markose
    Age 55
    Lives alone, wife dead 2 yrs back, 1 son settled in Newsland.
    Admission date 10/6/2020
    Discharge date 15/6/2020
    Reason for admission. Fatigue, severe abdominal pain, fever&vomiting.
    Emergency USG performed-ruptured appendix with fluid filled abdomen.
    Laparoscopy+abdominal drainge. 300ml fluid drained.
    Nursing management:
    Iv fluids
    Antibiotics
    Post op day 3
    Patient complaint severe pain &weakness
    Morphine given, Iv fuids
    Past medical history. Hypertension since 2009,lababetol 100 mg tid, thyriodectomy 5 yr back. Asthmatic on ventolin inhaler.
    Allergies:egg and nuts
    Smokes 20 cigarette per day, occational drinker, sedentary lifestyle.
    Made significant improvement
    Ready for discharge.
    Discharge plan:
    2 wks rest
    Antibiotics and pain killers
    Follow up visit after 2 wks
    Arranged meals on wheals

    Writing task. Using the information write a letter to district nurse and request homevisits for further care and assistance.

  5. Today’s date
    15/07/2019

    Helen Marshal is a resident at the Wellness
    Retirement Village. She needs urgent admission
    to hospital. You are the registered nurse looking after
    her.
    Patient Details

    Address: Wellness Retirement Village
    Waterford St
    Berkeley, 4101
    Phone: (07) 3441 3257
    Date of Birth: 29/01/1968
    Marital Status: Widowed
    Country of birth: Australia

    Social History:
    Moved to Retirement Village following the death
    of husband due to a heart attack in December 2017.
    Next of kin: Son, Benjamin Marshal, 53 Gladison
    Street, Warwick 4370, Ph (07) 4693 6552.
    Normally alert and orientated. Enjoys reading
    Watching television.

    Medical History
    Hypertension- last 10 years
    Smoker- 1 pack/day stopped 5 years ago.
    Alcohol- 2 glass of wine at bedtime daily
    Glaucoma since 2010
    Allergic to codeine

    Prescription Medications
    Captopril 25 mg b.i.d
    Timoptol Eye Drops 0.5% 1drop each eye am & pm
    Normison 20 mg prn

    Non prescription Medication
    Golden Glow Glucosamine Tablet – 1 with
    breakfast for joint pain
    Vitamin C Complex Sustained Release – 1 with lunch

    Mobility / Aids
    Independent with walking frame. Arthritis in
    hands. Wears contact lenses Continence: Requires
    continence pad

    Recent Nursing Notes

    28/06/2019
    Flu vaccination-influenza type B prophylaxis

    12/07/2019 20:45
    Complaining of epigastric pain and indigestion following evening
    meal. pain settled with Buscopan tablets p.o

    13/07/2019 21:20
    Unable to sleep – aches in shoulder. Settled
    following 2 Panadol and Diclofenac 75mg intramuscular
    slept well

    15/07/2019 19:45
    Tired and feeling generally weak. BP 180/95.
    Confined to bed. GP was called and will visit tomorrow am- was busy
    Requested buscopan for indigestion,Panadol for
    shoulder pain

    15/07/2019 20:00
    Buscopan tab ,Panadol 2 tab p.o at 20:10
    Didn’t touch the evening meal. Says not feeling hungry, Trouble sleeping,BP 175/95
    Anxious- says want to see son before dies.

    Rechecked 20:25 – Distressed, pale and
    sweaty,complaining of tightness and pain in the chest, pain rated 8/10 on pain scale
    complaining of radiating shoulder and neck pain.
    Pain not relieved with buscopan and panadol.
    BP 190/100. Acute Myocardial infarction?? oxygen administered via nasal prongs 2 L/minute
    Nitroderm transdermal patch applied – still complaints of pain.
    Ambulance called and patient Transferred.

    Writing Task
    Write a letter to the emergency consultant of the
    Holy Spirit Hospital Emergency Department. Give the
    recent history of events and also the patient’s
    past medical history and reason for urgent referral.

Correct Usage 13 – Apostrophe

Day 14 Adjectives – Advanced