Day 15 Case Notes Analysis

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:



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.

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 (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.

Medical History

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


Under Prescription

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

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. Sound sleep for 7 hours.

15/07/2019 19:45

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

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 – 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.

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.

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

  • Question of

    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
  • Question of

    Who is the recipient?

    • Emergency Doctor
    • Emergency consultant
    • Charge nurse
  • Question of

    What is the purpose?

    • Emergency surgery
    • Emergency counseling
    • Emergency admission
  • Question of

    What is the admission / Discharge status?

    • Admitted
    • Discharged
    • Being discharged today
    • No admission – home-care
  • Question of

    What is the less relevant information?

    • Son’s paralysis
    • Over-the-counter medication
    • Detailed nursing notes (recent)
    • None of the above

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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One Comment

  1. 15July,2019

    The Emergency Consultant
    Holy Spirit Hospital

    Dear Doctor,

    Re : Mrs Helen Marshal,51 years

    I am writing to refer Mrs Marshal who requires your urgent assessment and further management
    She is suspected to have acute myocardial infarction and has been transferred today via ambulance.

    Two days ago,Mrs Marshal complained of epigastric pain and indigestion following an evening meal,for which she was treated with buscopan tablets.On subsequent day, she also reported insomnia and pain in the shoulder and was managed with analgesics.

    Today evening,Mrs Marshal was tired and confined to bed.On assessment, her blood pressure was elevated to 175/95.While re-checking after 10 minutes, she was found to be distressed,
    pale and sweaty.In addition,she has been experiencing severe chest pain and tightness radiating to the shoulder and neck.Consequently,she has been initiated with oxygen therapy at 2 litres per minute.Please note, she received Nitroderm patch transdermally.

    A resident at Wellness Retirement Village,Mrs Marshal has been hypertensive for 10 years and takes Captopril 25mg tablet twice daily.She also has glaucoma since 2010 and is being managed with Timoptol eye drops.She had been smoking 1 pack a day before she quit 5 years ago.She consumes 2 glass of wine everyday at bedtime and has a history of allergy to codeine.
    Currently,she is able to walk with the walking frame and wears contact lenses.

    It would be greatly appreciated if you could see Mrs Marshal and provide treatment as deemed appropriate.

    Please contact me for any information.

    Yours faithfully,

    Registered Nurse

Correct Usage 14 – Advice / Advise

Day 15 – Today’s Grammar