OET Case Notes 4.2 Nina Davies





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


You are Mr Philips Jones. You are the charge nurse on the medical ward where Mrs. Davies was admitted on 09/05/2023.

Hospital – Prince Wales Hospital

Patient details

  • Name: Nina Davies
  • Date of Birth: 25/12/1949
  • Address: 95, Eagle Vale Sydney
  • Occupation: Retired Librarian
  • Race: Caucasian
  • Marital Status: Married
  • Next of Kin: Thomas Davies, John Davies

Family Hx

  • Mother died at 40 – Cancer, Father died at 57 – Coronary Heart Disease
  • Has 2 siblings, brother aged 79 with CAD, twin sister with osteoporosis and depression.

Social History

  • Lives with husband Hayne Davies in own house. Home has 2 stories, 2 steps to entrance
  • Supports full bath on second floor only, 2 grown children living nearby;
  • is very active; walks 1-2 miles/day, stopped smoking 30 years ago;


  • Occasional drink, drinks a cup of coffee a day, reports diarrhoea and gas with dairy products;
  • Allergies: NKDA

Past Medical

  • 2022 à Diagnosed with osteoporosis;
  • First signs noted in 2021

Medical History

  • Mild hyperlipidaemia, Mild hypertension, Coronary artery disease, Tendonitis of R. Shoulder, PTCA, 2015, without recurrence


  • Simvastatin (Zocor) 20 mg. daily
  • Aspirin daily – pain in ribs and back
  • Furosemide (Lasix) 10 mg. daily
  • Alendronate (Fosamax) 10 mg. daily;
  • Calcium + Vit. D 600 mg. daily Vit. E, Vit. C, Mg

Admission & Discharge

  • Date of admission 09/05/2023
  • Date of discharge 13/05/2023
  • Chief Complaint Injury on the left hip – had a fall after slipping
  • Dx: Fractured L NOF

Nursing Management and Progress


  • Admitted Through ER, medical evaluation found her a good candidate for Left Hemiarthroplasty;


  • IV Fluids at 100 cc/hr;
  • Morphine 10 mg IM q. 4 hours (PRN for pain); IV famotidine (Pepcid) 20 mg. every 12 hours due to GI distress postop;
  • Cefazolin (Ancef) 1 g. IV q. 8 h. X 3 doses


  • Complaints of hip and back pain,
  • restless and confused with hallucinations – possibly due to morphine.
  • Doctor discontinued IM morphine,
  • Replaced with hydrocodone / acetaminophen 5 mg./325 mg. (Lortab) 1 or 2 q. 4 to 6 hours as needed for pain.
  • IV famotidine (Pepcid) switched to oral route Aspirin and furosemide restarted


  • PT (physiotherapy) started;
  • Complaints of dizziness and light-headedness almost resulting in a fall
  • Found to be hypotensive – diuretic (furosemide discontinued)


  • PT continued complaining of constipation (Not had a bowel movement since surgery)
  • Docusate 100 mg. daily
  • Can ambulate short distances with a walker
  • Assistance with ADL’s


  • Original dressing changed;
  • Ready for discharge

Discharge plan

  • LLE (Left lower extremity) wt. bearing limited to 30 % for next 6 weeks
  • Elderly husband not able to care for her; home not set up for a walker
  • Neither of children can take her in their homes- lack of space, too many Stairs, and working spouses.
  • Decision is made to transfer her to Helping Hand rehabilitation centre near her house
  • Continue Physio program and medication
  • Assistance with ADL
  • Staples to be removed on day 14
  • Dressings to remain dry & intact

Discharge medications:

  • Hydrocodone/acetaminophen 5 mg./325 mg.
  • (Lortab) 1 to 2 q. 4 to 6 hours prn pain
  • Acetaminophen 325 mg. 1 to 2 q. 4 to 6 hours prn headache or minor pain
  • Famotidine (Pepcid) 20 mg. b.i.d.
  • Docusate 100 mg. daily
  • Alendronate 10 mg. daily


Using the information in the case notes, write a referral letter to the Ms. Susan Parry, Charge Nurse at Helping Hand Rehabilitation centre, Eagle Vale, Sydney, NSW where Mrs. Davies will be transferred to from your ward.

In your answer

  • Expand the relevant case notes into answers
  • 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 English Melon

Biju John, author of ByeBle and Maclins, is an English Language Trainer. He has also authored his educational Fiction. All these titles are available on Amazon and Google. You can contact his office on WhatsApp / Telegram number +917510923061

Leave a Reply

Your email address will not be published. Required fields are marked *

GIPHY App Key not set. Please check settings

Case Notes 4.1 Joan Romana

Mention Practice – 4.1