Case Notes 3.4 Tom Clarke

Case Notes 3.4 Tom Clarke

WRITING SUB-TEST: Nursing

TIME ALLOWED:

Reading: 5 Minutes + Writing 40

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

NOTES:

You are Ramona Decosta, a senior nurse working with Helpline Hospital.

• Patient name: Tom Clarke
• DOB: 21/09/1955
• Address: 92 Lygon Street, Carlton, Melbourne
• Phone: 0422-894-896.

Social Background:

• Married Wife – “Miranda” Clarke, aged 58 years. Live together.
• Retired – Army officer.
• Two daughters – elder daughter works in Sydney, younger daughter – Adelaide.
• Quite active.
• Hobbies: Cycling, watching movies, sports, reading, travelling, playing golf and Tennis.

Surgical History:

• R Ankle dislocation surgery following a car accident, 1989.
• Hospitalized for 3 weeks.
• Septoplasty – 1991.
• Surgery for Anal Fistula – 1999
• Eye replacement lens surgery – 2014.

Medical History:

• Hypertension – 1992 (Did not seek treatment till 2007; now managed with Ramipril)
• GERD – 2006.

15/02/2023

• Accident with a motorbike while cycling, claimed he was going at a moderate speed, a motorbike hit him while overtaking, landed on the left side of his body.
• FOOSH (Fall on outstretched hand) injury to L elbow, presented to ER, limited range of motion and extreme pain.
• X-RAY – Nondisplaced fracture of the coronoid process of the ulna, marrow oedema head and neck of radius involving articular surface, moderate joint effusion.

Treatment

• Sling to keep the elbow immobilized- 6 weeks,
• Capsule CM Plus, Panadol, Ibuprofen, hot compress for pain and inflammation
• Next Appointment in 6 weeks’ time.

30/03/2023

• X-ray – injury healing well
• Tab DGain qw
• Tab CM Plus – qd
• Sling taken off
• Exercise program – at home.

29/04/2023 (today)

• Complains of stiffness and limited range of motion in the elbow
• Arrange home visits by physiotherapist for rehab program.
• Tab DGain qw
• Tab CM plus qd
• Follow-up appointment – 20/05/2023.

Writing task

Write a referral letter to Amit Kumar, Physiotherapist, Suite 5, 379 Swanston Street, Melbourne requesting home visits for the patient.

In your answer:

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