TASK 82: Today’s Date: 09/09/12.

Notes: You are Lee Wong a registered nurse in the Coronary Care Unit, St Andrews Hospital Brisbane. Bill O’Riley is a patient in your care.

Patient Details:  Name: Bill O’Riley

DOB 12 January 1959                      

Address: 9476 Old Dam Road, Goondiwindi QLD 4390

Next of Kin Brother: Ernie O’Riley 72 Burke St, Cunnamulla QLD 4490

Admitted 2 September 2012; Diagnosis Obstructive coronary artery disease

Operation Coronary artery bipass grafts (x 4) on 4th September 2012

Social History: Never married. Lives alone in own home just outside Goondiwindi. Fencing contractor

Medical History: Smokes 20 cigarettes/day. Alcohol: 2 x 300ml bottles beer / day. Ht 170cm Wt 99kg

Usual diet: sausages, deep fried chips, eggs, MacDonalds. Allergic reaction to nuts

Nursing Management and Progress: Routine post operative recovery

Advised to cease smoking, reduce alcohol. Low fat diet. Walking well. Wounds healing well

Routine visit from Social Worker

Discharge Plan: Returning Home to Goondiwindi

Appointment made for follow up visit to local GP Dr. Avril Jensen 2pm 15/9/12

Local physiotherapist to continue rehabilitation exercise program

Writing Task: Mr. O’Riley has requested advice on low fat dietary guidelines and healthy simple recipes. 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. O’Riley’s situation and the information he needs. Include Medical History, Body Mass Index and lifestyle. Information should be sent to his home address.

View sample answer by Lifestyle Training Centre

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