This case notes will be used for writing today’s letters for correction. Before you proceed to writing this letter on the writing page, please read this case notes and answer the questions that below:
OCCUPATIONAL ENGLISH TEST
WRITING SUB-TEST: Nursing
TIME ALLOWED: READING TIME: 5 MINUTES
WRITING TIME: 40 MINUTES
Read the case notes below and complete the writing task which follows.
Helen Marshal is a resident at the Wellness Retirement Village. She needs urgent admission to hospital. You are the registered nurse looking after her.
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
Moved to Retirement Village following the death of husband due to a heart attack in December 2017. Next of kin: Son, Benjamin Marshal (crippled for life after a right side-paralysis a month ago, Mrs Marshal not aware of this) 53 Gladison Street, Warwick 4370, Ph (07) 4693 6552.
Normally alert and orientated. Reading, watching television.
Hypertension – Last 10 years
1 pack cigarettes/day; “almost” stopped 5 years ago.
Alcohol – 2 glass of wine at bedtime daily
Glaucoma (since 2010)
Allergic to codeine
Captopril 25 mg b.i.d
Timoptol Eye Drops 0.5% 1 drop each eye am & pm
Normison 20 mg prn
Non Prescription Medication (Over the counter – when suggested by neighbors)
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 (hands). Wears contact lenses. Continence: Requires continence pad.
Recent Nursing Notes
Flu vaccination-influenza type B prophylaxis
Complaining of epigastric pain and indigestion following evening meal. Pain settled with Buscopan tablets p.o
Unable to sleep – Aches in shoulder. Settled following 2 Panadol and Diclofenac 75mg intramuscular. Sound sleep for 7 hours.
Tired and feeling generally weak. BP 180/95. Confined to bed. GP called and will visit tomorrow am – was busy. Requested buscopan for indigestion, Panadol for shoulder pain
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 – strong, persistent wish to see son. “Something is amiss. Why is he not paying a visit.”
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.
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.
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.
Now take this Case Notes Analysis and proceed to Letter Writing
Who is the patient?
An old woman crippled for life
An old woman with sleep disorders
An old woman with possibility of Acute myocardial infarction
Who is the recipient?
What is the purpose?
What is the admission / Discharge status?
Being discharged today
No admission – home-care
What is the less relevant information?
Detailed nursing notes (recent)
None of the above