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Case Notes 57.1

Case Notes 57.1 Janice Brown

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).

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

Notes:

Imagine that today is August 14, 2024. You are in charge of this patient at City Hospital, High Gate, Waterloo, UK.

Patient Details

  • Name: Janice Brown.
  • Age: 85
  • Residence: Sunny Meadows Old Age Home (since husband’s death).
  • Marital Status: Widowed (husband passed away 10 years ago)

Medical Background

  • Type 2 Diabetes Mellitus (diagnosed 22 years ago).
  • Osteoarthritis (diagnosed 10 years ago).
  • Chronic Kidney Disease (Stage 3). Diagnosed 3 years ago.
  • History of Stroke (2019).
  • Allergy: Penicillin (rash, difficulty breathing).
  • Father and mother had kidney disease.

Recent History

  • Admitted with confusion and generalized weakness.
  • Increased lethargy and decreased oral intake.
  • New onset of shortness of breath.
  • Uncontrolled blood sugar levels.
  • Weight loss of 4 pounds in the past month.

Admission & Discharge

  • Admission Date: 10 August 2024.
  • Discharge Date: 15 August 2024
  • Diagnosis: Exacerbation of Chronic Kidney Disease, Uncontrolled Diabetes Mellitus.

ED Record

  • Vitals on Admission: Temp 37.8°C, HR 105 bpm, RR 20, BP 160/95 mmHg, O2 Sat 89% on room air.
  • Labs: Elevated creatinine 2.5 mg/dL, Blood glucose 320 mg/dL, HbA1c 9.5%.
  • Treatment in ED: IV fluids, insulin therapy, oxygen therapy.

Nursing Care

  • Daily monitoring of vital signs and blood glucose levels.
  • Assistance with activities of daily living (ADLs).
  • Encouraging fluid intake and balanced diet.
  • Frequent repositioning to prevent pressure ulcers.
  • Physical therapy to improve mobility.
  • Patient education on diabetes management.

Discharge Medications

  • Metformin 500 mg twice daily.
  • Lisinopril 20 mg daily.
  • Glipizide 5 mg daily.
  • Aspirin 81 mg daily.
  • Multivitamin daily
  • Calcium with Vitamin D supplement daily

Discharge Plan

  • Follow-up appointment with GP Dr. Michael Spencer in 1 week.
  • Regular blood glucose monitoring.
  • Repeat kidney function tests in 1 week.
  • Continue daily vital signs and assessments.
  • Monitor for signs of hyperglycemia or hypoglycemia.
  • Ensure proper hydration and diet management.
  • Equipment Required: Walker, Blood glucose monitor, Nebulizer

Writing Task

Using the information in the case notes, write a letter to Ms. Richa Howard, head nurse at Sunny Meadows Old Age Home, 456 Meadow Lane, Norwich, where the patient will return after discharge, tomorrow.

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.

What do you think?

Written by Biju John

Hello, everyone! I'm Biju (IB). Welcome to Melons IB to build up your IB skills without being dependent. My field of expertise is IB English A. I am available for one-on-one tuitions. I believe that an IB student should not be helped to write, but think. Let's together start to end your IB trip!

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