Case Notes 5.4 Ava Fred Evans

OCCUPATIONAL ENGLISH TEST WRITING SUB-TEST: Nursing

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

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

NOTES:

Mrs Ava Fred Evans is a 72 years old patient in your care. She is now ready for discharge. She has just undergone a mitral valve replacement.

• Name: Mrs Ava Fred Evans
• Age: 72 years
• Admitted 25/05/2023
• Diagnosis: Valvular heart disease (Mitral valve prolapse)
• Reason for admission: Fainting, light-headedness, chest pain

Social History:

• Widow; Lives with daughter Mira,
• No longer drives,
• Enjoys reading / doing crosswords, chatty, friendly
• Smoker for 55 years (Still).

Medical history:

• Chronic bronchitis
• Hypertension (150/100)
• Chest infections since retirement 12 years ago

25/05/2023

• Admitted
• Valve Replacement
• Antibiotics/anticoagulant therapy
• Analgesics
• Prescribed Warfarin BID

26/05/2023

• Patient put on low salt diet
• Wear contact lenses
• Showering /dressing with help of nurses
• Slowly recovering from analgesics
• Able to walk/ stand-short periods of time

27/05/2023

• Recovered from analgesia
• Showering and dressing with help of nurses
• Pt educated about causes/
• preventions of infections

28/05/2023

• Pt advised to quit smoking/ given tips incl using patches.
• Pt was seen by dietician re low salt diet
• Able to walk for longer periods of times with walking stick.

29/05/2023

• Pt recovering well
• Can now shower/ dress independently
• Still using walking stick/ frame
• Pt informed of discharge on 31/05/2023
• Vital signs unremarkable

31/05/2023

• Discharge plan discussed with patient
• Discharged at 03.00 pm.

Discharge plan:

• Needs to rest
• Requires home help – to be visited by district nurse
• Patient to monitor medication usage
• Regular follow-up examinations
• INR – to be checked on regular basis
• Avoid invasive surgical or diagnostic procedures until prophylactic antibiotics are given
• Auscultatory assessment of heart

Current Medication:

• Warfarin (anti coagulation therapy)
• Salpetrol 3 puffs daily; Mirax 25 mg daily

WRITING TASK

Using the information in the case note, write a letter of referral to Ms Cindy Chest (district nurse), who will provide follow up care in this case. Ms Cindy Chest, 45 Finders Lane, Melbourne, 300.

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.