Case Notes 2.1 Sally McConville
Occupational English Test
Reading Time: 5 Minutes. Should not write during this time.
Writing Time: 40 Minutes
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
- Asthma, hypertension, cholecystectomy, ankle fracture, depression, non-smoker till 35 years.
- Ramipril 2.5 mg daily,
- Paroxetine, 20 mg daily,
- Fluticasone 250-2 puffs daily,
- Ventolin (salbutamol), 2 puffs PRN
- Allergies: Nil
- 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.
- Viral upper respiratory tract infection.
- Infective exacerbation of asthma.
- Ventolin 2 puffs 4-hrly, continue preventer
- Medical certificate for work
- Review as required
- 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.
- ↑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.
- No improvement. Still obvious respiratory distress.
- Refer to Emergency Department for acute management & investigation
- ? Pneumonia
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.