Case Notes 4.4 Martin Wilson

Occupational English Test

WRITING SUB – TEST: NURSING

TIME ALLOWED:
READING TIME: 5 MINUTES
WRITING TIME: 40 MINUTES

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

Notes:

The patient was admitted after an attempt to suicide and is coming back to a notably normal state.

• Today’s Date: 19 September, 2023
• Hospital: Lyell McEwin Hospital

Patient Details:

• Name: Martin Wilson
• Age: 62
• Admission Date: 09 September, 2023
• Discharge Date: 20 September, 2023
• Diagnosis: Attempted suicide — overdose of Mogodol.

Past Medical History:

• Heavy smoker (40 cigarettes/day).
• Bronchitis (multiple episodes).
• Underweight – 66 kg, BMI 18.

Social History:

• Retired 2 years ago (book-keeper with Holden Car)
• Lives with wife, Joan, and adult son in Housing Trust, Elizabeth.
• Wife works at Coles, son unemployed.
• 2 married daughters and 5 grandchildren.
• Regular social drinker.
• Used to be a keen lawn bowl player.

Gambling History:

• Depression related to gambling addiction
• Began gambling 2 years ago
• Has lost a lot of money including superannuation for debt.
• Wife and family previously unaware of addiction also upset about suicide attempt
• Patient remorseful and ashamed;
• Wants to overcome addiction.
• Has lost friends as result of gambling.

Nursing Management:

• Weak and depressed.
• Anti-depressants prescribed – Lovan 200 gm.
• BP 130/95
• Diagnosed with Type II diabetes.
• Diabetes education regarding diet and oral medications;
• Wheelchair use from 20/10
• Psoriasis on Torso and scalp – Diprosone OV cream 2x/day, Ionil T Shampoo.
• Poor appetite
• Physically unfit.

Discharge Plan:

• Encouragement to maintain anti-depressant medication routine as the SSRI is established.
• Mrs Wilson will help with supervision.
• Monthly follow-up appointments with psychologist Dr Brian Murphy, Lyall McEwen Hospital.
• Social worker appointment to be made for gambling addiction therapy.
• Strong encouragement and assistance to join Gambling Addiction Action Group, Elizabeth Community Centre.
• Contact with Quitline needs to be encouraged.
• Wheel chair required for another week.
• Frame advised after this
• Maintain psoriasis treatment
• Maintenance of low GI diet for diabetes –
• Involvement of wife necessary.
• Encouragement in social sporting activities (eg: lawn bowls?)

WRITING TASK

Using the information in the notes, write a letter to the social worker, Ms Jennifer Adams, at the Elizabeth Community Health Centre, 125 Munno Parra Avenue, Elizabeth, 5098 requesting follow-up care. Stress that Mr Wilson’s case needs urgent attention.

In your answer

• Expand the relevant case notes into complete sentences;
• Do not use note form;

Use letter format