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Day 24 Case Notes Analysis

OCCUPATIONAL ENGLISH TEST

WRITING SUB-TEST: Nursing
READING TIME: 5 MINUTES | WRITING TIME: 40 MINUTES

Read the case notes below and complete the writing task which follows.

Notes:

Today’s date: 12/09/2020

You are an Emergency Department Nurse who is caring Mr Alby Chripps, a 41-year-old man.

Patient Details
Name: Mr Alby Chripps
Age: 41 years

Social Background
Lives with mother, wife, two children
Employed as painter
Smokes and drinks moderately
Presenting complaints – Hit his left hand against concrete wall

Past Medical History
Left tibial fracture in 2006
Concussion in 2018

GP Notes:

  • The Patient hit his left hand against wall after an argument (with a neighbor)
  • Assessment: Tenderness on 4th and 5th finger and painful
  • 5th metacarpal tenderness
  • ? Boxer fracture
  • An X-ray revealed Boxer fracture to left 5th metacarpal
  • Diagnosis: Left 5th metacarpal fracture
  • Current medications: Paracetamol for headache, Morphine IV for pain
  • Management: Closed reduction and immobilization of 5th metacarpal (fiber glass cast)
  • Medications as per chart
  • Monitor vital signs and needs ongoing care from Orthopedic clinic

Nursing assessment:

  • Vital signs normal
  • Neurological status monitored
  • Elevate hand
  • Medications as per chart

Discharge advice:

  • Provide cast care
  • The Patient was educated on cast care
  • Elevate left hand with a sling Physiotherapy at ‘‘Hand Clinic’’ Review in a week at OPD with follow-up X-ray Return Emergency Department in case of worsening symptoms like numbness, pain and tenderness Medical certificate requires

WRITING TASK:

Using the information in the case notes, write a referral letter to Ms Rio Helsinki Nurse Practitioner at OPD, NSW 2154 for ongoing care. Dietician for specialized management.

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

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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4 Comments

  1. Ms Rio Helsinki
    Nurse Practioner
    Out Patient Department
    NSW 2154
    12 September,2020
    Dear Ms Rio Helsinki,
    Re: Mr Alby Chripps, 41 years

    I am writing regarding Mr Alby Chripps, who requires further ongoing care and assistance. He has been treating for left 5th metacarpal fracture. He is being transferred to your facility.

    Mr Alby was brought to the hospital followed by left hand hit against wall. On assessment he has tenderness and pain on 4th and 5th fingers. An X-ray revealed that Boxer fracture of 5th metacarpal bones. He was diagnosed with left 5th metacarpal fracture. For which his treatment was commenced on paracetamol, Morphine. He was advised for closed reduction and immobilisation of 5th metacarpal.

    Mr Alby lives with his family. He is works as a painter. He has a previous history of left tibial fracture and contusion in 2016 and 2018 respectively. He is also drinking and smokes moderately.

    In view of the above, it could be greatly appreciated if you could provide necessary ongoing care to Mr Alby. Kindly provide cast care and elevation of left hand with a sling. Of the note he has follow-up review with X- ray report. If you find any symptoms like numbness, pain and tenderness please return emergency department at any time. Kindly make a consultation with Dietitian for specialized management.

    If you have any queries kindly contact me.

    Yours faithfully,
    Register Nurse
    Emergency Department

  2. Ms Rio Helsinki
    Nurse Practioner
    Out Patient Department
    NSW 2154
    12 September,2020
    Dear Ms Rio Helsinki,
    Re: Mr Alby Chripps, 41 years

    I am writing regarding Mr Alby Chirpps, who requires further ongoing care and assistance. He has been treating for left 5th metacarpal fracture. He is being transferred to your facility.
    Mr Alby was brought to the hospital followed by left hand hit against wall. On assessment he has tenderness and pain on 4th and 5th fingers. An X-ray revealed that Boxer fracture of 5th metacarpal bones. He was diagnosed with left 5th metacarpal fracture. For which his treatment was commenced on paracetamol, Morphine. He was advised for closed reduction and immobilization of 5th metacarpal.
    Mr Alby lives with his family. He is works as a painter. He has a previous history of left tibial fracture and contusion in 2016 and 2018 respectively. He is also drinking and smokes moderately.
    In view of the above, it could be greatly appreciated if you could provide necessary ongoing care to Mr Alby. Kindly provide cast care and elevation of left hand with a sling. Of the note he has follow-up review with X- ray report. If you find any symptoms like numbness, pain and tenderness please return emergency department at any time. Kindly arrange a consultation with Dietitian for specialized management.

    If you have any queries, kindly contact me.

    Yours faithfully,
    Register Nurse
    Emergency Department

  3. September 12, 2020

    Ms. Rio Helsinki
    Nurse Practitioner
    Out-Patient Department
    NSW 2154

    Re: Mr. Alby Chripps, Aged 41 years

    Dear Ms. Helsinki,

    I am writing to refer Mr. Chipps who requires further ongoing care. He presented with a complaint that he hit his left hand against the wall after having an argument with his neighbor.

    Upon Assessment by the GP, his 4th and 5th fingers were tender and painful. The X-ray result showed that he has a Boxer fracture on his left 5th metacarpal. He commenced on Paracetamol and Morphine intravenously. Consequently, all the necessary assessments and monitoring were completed his vital signs are within normal. Most importantly his affected hand was elevated. In addition, the patient was educated regarding cast care.

    I will now transfer Mr. Chripps to your care. It would be greatly appreciated if you could provide the necessary ongoing care for his recuperation. Please take note that his hand needs to be elevated with sling physiotherapy at a Hand Clinic followed by a review in a week at Out-patient Department together with a follow-up X-ray. If Mr. Chripps suffers worsening of symptoms such as numbness, pain, and tenderness. For this reason, advise him to return to the Emergency Department together with his medical certificate immediately. Also, please set an appointment for him with a Dietician for specialized management.

    Should you have any queries. Please do not hesitate to contact me.

    Sincerely yours,

    Emergency Department Nurse

Day 7 – Medical Terms & Abbreviations

Labels – Detailed List