TASK 59. You are a nurse visiting Ms Styles at her home who is taking self care at home
PATIENT HISTORY. Name: Ms Patricia Styles
Age:04/08/1955 (63 years)
MEDICAL BACKGROUND: Hypertension diagnosed in 2012, on Carpinol medicine, blood pressure 2014 (190/100) Now BP under control (140/90)
Diabetes Mellitus diagnosed in 2009 (Type II), taking oral hypoglycemic (Metformin+Glipizide)
Depression diagnosed first in 2015, depressed after her husbands
death, attends medical counseling for mood swings and diabetes mellitus management
SOCIAL BACKGROUND: Hobbies walking, reading
Lives alone, no close relatives, her cousin helps her sometimes Medications
Carpino! 6.25 x 2 times daily Metformin- 500mg x 2 times daily Glipizide 10mh x I daily
MEDICAL HISTORY: On 07/04/2018 she admitted in Green Valley Hospital with chest pain (pleuritic),shortness of breath(SOB), tiredness.
Management: Glucose monitored regularly, sugar and BP (well controlled)
Blood test: ESR (24). Creat (2.0). Platelets (Stress/inflammation)
Oral throat swab Type B influenza Chest X-ray Normal Echocardiogram Pericarditis
Diagnoşis: Type B influenza plus pericarditis
Treatment: IV saline, Antibiotics
Discharged on 09/04/2018 advising further follow up home visits
She was on self home care after discharge. She was keeping well and the home nurse left her 2 days ago.
14/04/2018 Home visit: Subjective:Ms Styles feels tired and has chest pain Examination Unwell, Chest pain (when sitting), SOB, fatigue Vital signs Mild temperature (38), HR-122, RR-28. BP-180/90 Assessment ?? Relapse/Complication pericarditis
Plan: Refer patient to Newtown Hospital Emergency Department (nearest hospital) Inform emergency doctor about patients: Medical history Medications Past history
WRITING TASK: Write a referral letter for MS Styles to the Emergency Doctor on Duty requesting urgent assessment and management of her pericarditis. Address the letter to: Emergency Doctor on Duty. Newtown Hospital, Comer Street, Newtown 1104.
Submit your OET letters for correction: (for a minimal fee)
https://goltc.in/oet-writing-correction/