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Day 7 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:

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.

NOTES

As Hey Bravis, you are the charge nurse on the medical ward of Prince Wales Hospital where Mrs H Rochester has been admitted.

Patient Details

Name: Mrs H Rochester
Date of Birth 25/12/1953
Address 39, Noose Brink, Sydney
Occupation: Retired Librarian
Race: Caucasian

Marital Status – Married
Next of kin – Thomas Rochester, John Rochester (The latter will visit her once a week)

Family Hx:

  • Mother died at 40 – Cancer,
  • Father died at 57 – coronary Heart disease,
  • Has 2 siblings, brother aged 69 with CAD,
  • Twin sister with osteoporosis and depression.

Date of admission 28/6/2020
Date of discharge 02/07/2020

Chief Complaint: Injury on the left hip – had a fall after slipping; Dx Fractured L NOF

Social History

Lives with husband in own house (2 stories, 2 steps to entrance; supports full bath on second floor only). 2 grown up children living nearby. Pt. is very active; walks 1-2 miles/day, stopped smoking 30 years ago.

Diet: Occasional drinks, drinks a cup of coffee a day, reports diarrhoea and gas with dairy products

Allergies: NKDA

Past Medical History

Diagnosed with osteoporosis
First signs noted in 2015
Mild hyperlipidaemia, Mild hypertension, Coronary artery disease, Tendonitis of R. Shoulder, PTCA, 2009, without recurrence.

Medications

  • Simvastatin (Zocor) 20 mg. daily
  • Aspirin daily – pain in ribs and back
  • Furosemide (Lasix) 10 mg. daily
  • Alendronate (Fosamax) 10 mg. daily
  • Calcium + Vit. D 600 mg. daily
  • Vit. E, Vit. C, Mg

Nursing Management And Progress

28/06/2020

  • Admitted through ER, medical evaluation found her a good candidate for Left Hemiarthroplasty.
  • Hemiarthroplasty performed at 2.00 PM

Post-opt:

  • IV Fluids at 100 cc/hr, morphine 10 mg IM q. 4 hours as needed for pain, IV famotidine (Pepcid) 20 mg. every 12 hours due to GI distress postop, cefazolin (Ancef) 1 g. IV q. 8 h. X 3 doses

29/06/2020

  • Complaints of hip and back pain,
  • Pt. restless and confused with hallucinations – possibly due to morphine
  • Doctor discontinued IM morphine, replaced with hydrocodone/acetaminophen 5 mg./325 mg. (Lortab) 1 or 2 q. 4 to 6 hours as needed for pain.
  • IV famotidine (Pepcid) switched to oral route
  • Aspirin and furosemide restarted

30/06/2020

PT (physiotherapy) started, complaints of dizziness and light-headedness almost resulting in a fall. Found to be hypotensive- diuretic (furosemide discontinued)

01/07/2020

  • PT continued complaining of constipation – not had a bowel movement since surgery
  • Docusate 100 mg. daily
  • Can ambulate short distances with a walker
  • Assistance with ADL’s

02/07/2020

  • Original dressing changed; ready for discharge
  • Discharge plan LLE (Left lower extremity) wt. bearing limited to 30 % for next 6 weeks
  • Elderly husband not able to care for her;
  • Home not set up for a walker
  • Neither of children can take her in their homes – lack of space, too many stairs, and working spouses.
  • Decision is made to transfer her to Helping Hand rehabilitation Centre near her house
  • Continue Physio program and medication
  • Assistance with ADL
  • Staples to be removed on day 14
  • Dressings to remain dry & intact

Discharge medications:

  • Hydrocodone/acetaminophen 5 mg./325 mg. (Lortab) 1 to 2 q. 4 to 6 hours prn pain
  • Acetaminophen 325 mg. 1 to 2 q. 4 to 6 hours prn headache or minor pain
  • Famotidine (Pepcid) 20 mg. b.i.d.
  • Docusate 100 mg. daily
  • Alendronate 10 mg. daily

Writing Task

Using the information in the case notes, write a referral letter to the Ms. Nikita Allen, Charge Nurse at Helping Hand Rehabilitation Centre, Eagle Vale, Sydney, NSW where Mrs H Rochester will be discharged to from your ward.

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.

Check your analytical skills!

  • Question of

    NKDA is medical abbreviation for:

    • No Known Disabilities
    • Northern Kentucky Dietetic Association
    • Non-Ketotic Diabetic Acidosis
    • None Known Drug Allergies
  • Question of

    Osteoporosis:

    • is a type of arthritis that occurs when flexible tissue at the ends of bones wears down
    • refers to a marked softening of your bones, most often caused by severe vitamin D deficiency
    • is a condition in which bones become weak and brittle
  • Question of

    Hyperlipidaemia refers to:

    • an abnormally lowered levels of any or all lipids and/or lipoproteins in the blood
    • a condition in which there are high levels of fat particles (lipids) in the blood.
    • low blood sugar, the body’s main source of energy
  • Question of

    Tendonitis is a condition:

    • that causes pain on the inner side of the elbow
    • such as irritation of the tissue connecting the forearm muscle to the elbow
    • in which the tissue connecting muscle to bone becomes inflamed
  • Question of

    PTCA stands for:

    • Percutaneous transluminal coronary angiogram
    • Percutaneous trans-dermal coronary angioplasty
    • Percutaneous transluminal coronary angioplasty
  • Question of

    ‘Dx Fractured L NOF’ is an abbreviation for:

    • Surgery done for the left neck of femur
    • Medicated for fracture of the left neck of femur
    • Diagnosed as fracture of the left neck of femur
  • Question of

    ‘Hemiarthroplasty’ refers to:

    • surgical procedure that involves replacing the entire hip joint
    • surgical procedure that involves replacing half of the hip joint
  • Question of

    What is not directly related to CAD?

    • Heart
    • Arteries
    • Blood
    • Lungs
  • Question of

    Is this a single patient letter of multiple patient letter?

    • Single
    • Multiple
  • Question of

    Who is the patient?

    • A postoperative young woman
    • A postoperative young man
    • A postoperative old woman
    • A postoperative old man
  • Question of

    Is it a single purpose letter or multipurpose letter?

    • Single Purpose
    • Multi-purpose
  • Question of

    What is the purpose of this letter?

    • Treatment
    • Advice
    • Information
    • Rehabilitative care
    • Request for home care
  • Question of

    Who is the recipient of this letter?

    • Family member
    • Doctor
    • Nurse
  • Question of

    What is the admission / discharge status?

    • Discharged
    • Not decided
    • Today
  • Question of

    What is the least relevant information in this case notes?

    • Social History
    • Discharge Medication
    • Al the admissions
    • Current medication
  • Question of

    Is the case known to the recipient?

    • Yes
    • No

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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2 Comments

  1. 02 July,2020

    Ms Nikita Allen
    Charge Nurse
    Helping Hand Rehabilitation Centre
    Eagle Vale
    Sydney
    NSW

    Dear Ms Allen,

    Re : Mrs H Rochester, DOB: 25 December,1953

    I am writing to refer Mrs Rochester who requires further support and care during her rehabilitation.She has been recovering from a left hemiarthroplasty and is being discharged today.

    Mrs Rochester was admitted on 28 June with a fractured neck of the left femur following a fall at her home and underwent the above mentioned surgery successfully.Postoperatively,she was managed with analgesics and antibiotics.On subsequent days,she has been initiated with physiotherapy sessions.In addition to this, she has been provided assistance in activities for daily living.Currently,she is able to walk short distances with the help of a walker.

    Mrs Rochester lives with her husband in a two-storied house and they have two children who live nearby.Following discharge,her husband is not able to take care of Mrs Rochester because of his old age and their children find it difficult to manage her at their home due to the lack of household facilities.She has mild hyperlipidemia,hypertension and coronary artery disease.

    In view of the above information,kindly take over the care of Mrs Rochester and continue to monitor her medication compliance.A detailed list of her current medications is attached with this letter.Please note,she has been advised to limit weight bearing upto 30% on her left leg for the next six weeks.Kindly make sure that her wound dressings are dry and intact and her staples need to be removed on day 14.

    Please contact me for any queries.

    Yours sincerely,

    Hey Bravis
    Registered Nurse

  2. 02 July,2020

    Ms Nikita Allen
    Charge Nurse
    Helping Hand Rehabilitation Centre
    Eagle Vale
    Sydney
    NSW

    Dear Ms Allen,

    Re : Mrs H Rochester, DOB: 25 December,1953

    I am writing to regarding Mrs Rochester, who is recovering from femur fracture. She is being discharged and now, requires care and support at your care facility.

    On 28th June , Mrs Rochester was diagnosed with left femur fracture after a fall, for which she has undergone hemi arthroplasty. Postoperatively, she had hypotension, resulting in her ceasing her diuretic medicine. Although she is able to ambulated with a walker, she needs assistance for her ADL. As per treatment plan, she has been instructed to limit her weight bearing on her left lower limb. Currently, she is making good progress.

    Mrs Rochester lives with her husband and has two adult children who live near by. In regards to her lifestyle, she leads active and drinks alcohol occasionally after quitting her smoking habits 30 years ago. In terms of medical history, she has had osteoporosis since 2015 and underwent PTCA in 2009. She also has had hypertension, hyperlipidemia, coronary heart disease and right shoulder tendinitis. I have attached her discharge medication list.

    In view of the above it would be greatly appreciated if you could welcome Mrs Roschester into your care facility. Please continue her Physio therapy and kindly monitor her compliant with her medication. Please be aware that her stables to be removed on day 14. It is important to note that she reports diarrhoea and gas with diary products

    If you have any questions please do not hesitate to contact me .

    Yours sincerely
    Register Nurse

OET Reading 1 – The M Method

Day 8 Case Notes Analysis