Case Notes 5.3 Noah Di Caprio

Occupation English Test: Writing

TIME ALLOWED:

READING: 5 MINUTES | WRITING: 40 MINUTES

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

Notes:

Today’s Date: 11/10/2023

You are Lee Wong a registered nurse in the Coronary Care Unit, St Andrews Hospital, Brisbane. Noah Di Caprio is a patient in your care.

Patient Details

• Name: Noah Di Caprio (Mr); DOB 12 January 1959
• Address: 9476 Old Dam Road, Woodwind Q4390.
• Next of Kin Brother, Ernie Oriel 72. Bedford St, Jericho, Q4490.
• Admitted 04/10/2023
• Diagnosis: Obstructive coronary artery disease.
• Operation Coronary artery bypass grafts (x 4) on 06/10/2023

Social History

• Never married. Lives alone in own home just outside, Woodwind.
• Fencing contractor.

Medical History

• Smokes 20 cigarettes/day. Smoked 40+ cigarettes / day till 2022.
• Chain-smoker till 2020. Alcohol: 2 x 300 ml bottles beer / day
• Ht 170cm; Wt 99kg (BMI 34)
• Usual diet: Sausages, deep fried chips, eggs, MacDonald’s;
• Allergic reaction to nuts.

Nursing Management and Progress

• Routine post-operative recovery slow.
• Advised to cease smoking, reduce alcohol.
• Patient not willing to cease smoking. Says, “it kills.”
• Has considerably reduced drinking.
• Commenced low fat diet. Walking well. Wounds healing well.
• Routine visit from Social Worker.

Discharge Plan

• Going to Jericho on day fifth from discharge to stay with brother.
• Appointment made for follow up visit to local GP Dr. Avril Jensen 2 pm 15/10/2023.
• Local physiotherapist to continue rehabilitation exercise program for five days.
• Arrange meeting with Mr Steeth Singh, Tobacco Cessation Specialist, Jericho: Phone 666773434.

Practical Advice to Cease Smoking

• Involve patient in socialization.
• Nicotine patches (tried but is averse to continue)
• Electronic cigarettes (Recently tried but there is a fear of getting addicted to Electronic Cigarettes).
• Involve patient in Smoking Cessation Councils and Counselling.

Writing Task 1

Write a letter to Mr Steeth Singh, Tobacco cessation Specialist, Gregory Terrace, Brisbane. Use the relevant case notes to explain Mr Di Caprio’s situation. Include Medical History, Body Mass Index and lifestyle along with a detailed smoking history.

Writing Task 2 (Optional)

Write a letter to the Community Information Section of the Heart Foundation, Gregory Terrace, Brisbane on the patient’s behalf. Use the relevant case notes to explain Mr Di Caprio’s situation and the information he needs. Include Medical History, Body Mass Index and lifestyle. Information should be sent to his home address.

In your answer:

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

The body of your letter should be approximately 200 words.