Case Notes 3.4 Tom Clarke
WRITING SUB-TEST: Nursing
Reading: 5 Minutes + Writing 40
Read the case notes below and complete the writing task which follows.
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.
- 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.
- 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.
- Hypertension – 1992 (Did not seek treatment till 2007; now managed with Ramipril)
- GERD – 2006.
- 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.
- 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.
- X-ray – injury healing well
- Tab DGain qw
- Tab CM Plus – qd
- Sling taken off
- Exercise program – at home.
- 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.
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