Case Notes 2.1 Sally McConville

Case Notes 2.1 Sally McConville

Occupational English Test

Writing: Nursing

Reading Time: 5 Minutes. Should not write during this time.
Writing Time: 40 Minutes

Notes:

You are a nurse in charge of the patient who has been visiting your clinic for the past couple of days.

Today’s Date: 18/09/2023

• Patient: Sally McConville (Ms), aged 38
• Occupation: Administrator
• Marital Status: Single

Past History:

• Asthma, hypertension, cholecystectomy, ankle fracture, depression, non-smoker till 35 years.

Medications:

• Ramipril 2.5 mg daily,
• Paroxetine, 20 mg daily,
• Fluticasone 250-2 puffs daily,
• Ventolin (salbutamol), 2 puffs PRN
• Allergies: Nil

15/09/2023

• 2-day history of runny nose; cough productive of yellow sputum;
• Slight fever; wheezy but not short of breath.
• Asthma usually well-controlled on preventer (fluticasone 250-2 puffs daily)
• Temperature 37.5; Pulse 82; BP 120/80, RR 12; Obvious nasal congestion; Throat red; Ears normal;
• No increased work of breathing, no accessory muscle use, chest scattered wheeze, no crepitations.

Assessment

• Viral upper respiratory tract infection.
• Infective exacerbation of asthma.

Treatment ++

• Ventolin 2 puffs 4-hrly, continue preventer
• Medical certificate for work
• Review as required

17/09/2023

• Increasing shortness of breath & wheeze over last 24hrs, feeling feverish at times, minimal yellowy sputum, short of breath on minimal exertion.
• Examination: Temperature 38, pulse 95, BP 120/80, respiratory rate 16, throat red, ears normal, mildly increased work of breathing, chest-widespread wheeze, no crepitations.
• Assessment: Infective exacerbation of asthma- symptoms worse.
• Treatment: Amoxicillin 500 mg 3 x daily, prednisolone 25 mg daily x 3 days Continue 4-hourly Ventolin & preventer.

18/09/2023

10.30 am

• ↑Short of breath today despite prednisolone & antibiotics.
• Feeling feverish & unwell.
• Examination: Short of breath at rest, respiratory rate 25, obvious accessory muscle use & increased work of breathing, pulse 112, BP 100/65, temp 37.7, chest exam- widespread wheeze, binasal crepitations
• Assessment: Acute asthma, ? Pneumonia.
• Treatment: Ventolin Nebules (salbutamol) 5mg, review.

10.45 am

• No improvement. Still obvious respiratory distress.
• Refer to Emergency Department for acute management & investigation
• ? Pneumonia

Writing Task

Using the information given in the case notes, write a letter of referral to the Admitting Officer at the Emergency Department, Newtown Hospital.

In your answer:

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

Your letter should have a word count of 180 – 200 hundred words. However, the numbers can go up or down depending on the relevance of information.