Case Notes 41 Nursing

Occupational English Test

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.

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

Notes:

Assume that today’s date is 22 April, 2024. The patient will be discharged today.

Notes:

• Name: Mr. Timothy Lawrence (Mr).
• DOB: 3 May 1955.
• Address: 01 Red Stones, Greenville; Phone: Not available.
• Admission Date: 17 April, 2024.

Social history:

• Lives with wife and daughter-in-law; Retired officer. Did managerial work till last year.
• No alcohol; Smokes 25 cigarettes per day.
• Weight 105 kg.

Medical History:

• 2017 – Hypertension – Ramipril.
• Osteoarthritis (knee, 2015; hip, 2018)
• Overweight. Counselled for weight reducing exercise.

Presenting Complaint

• Fell at home. Seven times last three months.
• Altered sensation and confusion.
• Weakness on upper and lower limbs.
• Right side weakness (arm and leg).
• Facial droop.

Assessment

• BP 205/105. Pulse irregular. Saturation 90.

Physical examination:

• Weakness on muscle.
• ? Disorientation left side.

Investigation

• Blood test and ECG normal.
• CT shows bleeding – atherosclerosis, low blood flow.
• Ischemic stroke, diagnosed.

19 April, 2024

• Reluctant to move (pain), uses walker frame.
• Pressure ulcer on left hip (on hydrocolloid dressing).
• Urinary tract infection (on antibiotics).
• Health education regarding diet, exercise and smoking given.
• Discharge in 3 days.

Discharge Plan

• Monitor medication compliance.
• Community nurse. Change dressing twice weekly.
• Monitor UTI symptoms with midstream urine after antibiotic completion.

Writing Task

Using the information in the case notes, write a letter to the community health nurse for continued care of patient at home. Address the letter to community health nurse, district nursing service, Greenville community health care centre, 88 Highton Road Greenville.

In your answer:

• Expand the relevant notes into complete sentences (Do not use note form).
• Eliminate irrelevant details.
• Organize the Punctuate appropriately with small and capital letters, full-stops, commas.
• Use correct grammar. Insert “the” before body parts / organs.
• Use letter format. DADR, PRPDD / TT, V/W and S/F.

The body of the letter should be approximately 180–200 words. Do not pick your pencil during the 5 minutes of reading time.