Case Notes 11.1 Dulcie Wood

OCCUPATIONAL ENGLISH TEST

WRITING SUBTEST: NURSING

Time Allowed:

READING TIME: 5 MINUTES; WRITING TIME: 40 MINUTES

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

Notes:

This new patient has been presenting for the last few weeks in King’s Hospital where you are the patient’s charge nurse. She has recently moved to be near family.

• Today’s Date: 20/11/2023

Patient History

• Dulcie Wood; DOB 15.07.60

16/10/2023

Subjective

• Widowed January 16, three children, wants regular check-up.
• Has noticed uncomfortable feeling in her chest several times in the last few weeks like a heart flutter.
• Mother died at 52 of acute myocardial infarction.
• Now, non-smoker. Quit smoking ten years ago.
• Rarely drinks alcohol.

Current Medication:

• Zocor 20 mg daily; Calcium Caltrate 1 daily.

Objective

• BP 145/75; P 80 regular
• 160 cm; Wt. 61 kg
• Cardiovascular and respiratory examination: Normal
• ECG: Normal

Plan

• Prescribe Noten 50 gm ½ tablet daily in am.
• Advise to keep record of frequency of fibrillation sensation.
• Review in 2 weeks if no increase in frequency.

01/11/2023

Subjective

• Reports sensations less but woke up twice at night during last 2 weeks.

Objective

• BP 135/75; P 70;

Assessment

• Increase Noten to 50 gm daily ½ tablet am and ½ tablet pm.
• Advise review in 20 days – 1 month.

20/11/2023

Subjective

• Initial improvement but in last 3 days heart seems to be fluttery several times a day and also at night.
• Very nervous and upset.
• Wants a referral to a cardiologist Dr. Vincent Raymond who treated her sister for same condition.

Objective

• BP 180/90; P 70.

Discharge Plan / Action

• Contact Dr. Raymond’s receptionist and you are able to arrange an appointment for Mrs. Wood at 8 am on 21/11/2023

Writing Task

Based on your communication with Ms Nancy Plus, Dr Raymond’s receptionist, you have been able to arrange appointment for the patient. Now, prior to the appointment, write a letter addressed to Dr. Vincent Raymond, 422 Wickham Terrace, Brisbane 4001 describing the situation.

In your answer:

• Expand the relevant case notes into complete sentences
• Do not use note form
• Use correct letter format

The body of your letter should be approximately 200 words.