Case Notes 30 Nursing

Occupational English Test – Writing (Nursing)

Instructions:

• You have 45 minutes to write this letter.
• During the first 5 minutes, you should not pick the pencil.
• Start writing only when you are told.
• During the Reading Time, try to understand the case notes.

Melons Steps

• Mark (M) PPRRAADDDDDWK.
• Eliminate (E) irrelevant information.
• Launch (L) the letter with DADR.
• Open (O) the letter with PRPDD or PRPTT.
• Narrate (N) the remaining paragraphs using V or W.
• Sign (S) the letter with S/F.

Melons Errors

• Punctuation “Marks”.
• Follow “Expansion” Rules.
• Obey “Language” Rules.
• Have an “Order” (DADR, PRPDD, V/W, S/F)
• Do not change “Names”.
• Sex (Mr, Ms, Mrs, His, Her).

Details to Fill In:

• CANDIDATE NAME. ROLE NUMBER.
• DATE OF BIRTH. VENUE OF THE TEST. TEST DATE.

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

Notes:

Today is July 11, 2024 and you are taking care of this patient at Hilltop Hospital, Booth. The patient will be discharged tomorrow.

Patient Details:

• Name: (Colonel) Fisher Mann.
• Age: 55 years.
• Nationality: American.
• Address: Currently posted in Booth, Canberra, ACT.
• Admission Date: 9 July 2024.
• Discharge Date: 13 July 2024.

Social Background:

• Military Officer, posted for a three-month assignment in Booth, Canberra, ACT.
• Lives alone in temporary military accommodation. Has a cook (Mr Arnold Rich) staying with him.
• Two dogs and an eagle.
• No family members in Australia.
• Has a wife and two adult sons in Philadelphia, US.

Medical History:

• Hypertension (diagnosed in 2015), managed with Lisinopril 10 mg daily
• Very active. Does rigorous exercise. Hits a local Gym. Takes protein supplements in high amounts.
• Type 2 Diabetes Mellitus (diagnosed in 2018), managed with Metformin 500 mg twice daily
• No known allergies.
• Non-smoker, occasional alcohol consumption

9 July 2024:

• Admitted to Hilltop Hospital following a car accident.
• Diagnosed with multiple bruises, minor lacerations, and a fractured right leg.
• Underwent surgery to set the fractured leg on 10 July 2024.
• Post-operative recovery, currently stable.

Present Condition:

• Recovering from surgery. Stability expected in a week.
• Pain management with Paracetamol 500 mg every 6 hours as needed.
• Antibiotics: Cefalexin 500 mg every 8 hours to prevent infection.
• Blood pressure and blood glucose levels are stable with current medications.
• Wounds take longer to heal due to overstraining with dogs (reports Mr Rich).
• Bled last night while restraining the bigger dog Ape.

Discharge Plan:

• Bed rest 1 month (ensure ↑ healing.
• Follow-up appointment 19 July (wound check, suture removal).
• Referral physiotherapy (after one month); aid needed with mobility, recovery).
• Paracetamol 500 mg every 6 hours PRN (pain).
• Continue Cefalexin 500 mg every 8 hours for 7 more days
• HTN, and DM, continue, PRN.
• Discuss referral to occupational therapy with family.
• Monitor BP and blood glucose levels (everyday).
• Contact Hilltop Hospital immediately if there are signs of infection (redness, swelling, or increased pain), or if blood pressure/blood glucose levels are unstable).

Writing Task:

Write a letter to Community Nurse Ms. Margaret Woods, community health centre, requesting home care and monitoring for Colonel Fisher Mann for the next month to assist with his recovery and ensure proper management of his conditions. Address the letter to Booth Community Health Centre, Green Park, Canberra, ACT

In your answer:

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

The body of the letter should be APPROXIMATELY 180-200 words.