Case notes:
Writing Task 5 Nurses
Time allowed: 40 minutes
Today’s Date
09/09/09
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 1956
Address 9476 Old Dam Road, Goondiwindi Q4390
Next of Kin Brother, Ernie O’Riley 72 Burke St, Cunnamulla Q4490
Admitted 2 September 2009
Diagnosis Obstructive coronary artery disease
Operation Coronary artery bipass grafts (× 4) on 4th September 2008
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 15/9/09
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.
In your answer:
- Expand the relevant case notes into complete sentences
- Do not use note form
- The body of the letter should not be more than 200 words
Use correct letter format
Sample letter by Lifestyle Training Centre
The Heart Foundation
Community Information Section
Gregory Terrace
Brisbane
09/09/2012
Dear Sir/Madam,
Re: Bill O’Riley, 12 January 1959
I am writing on behalf of Mr. O’Riley, who needs advice on low-fat dietary guidelines and healthy simple recipes. He is currently recovering from a Coronary artery bypass graft that he underwent on 4/09/2012.
Mr O’Riley was diagnosed with Obstructive coronary artery disease, and his post-operative recovery has been uneventful. He is able to walk well and his wounds are healing well.
Mr. O’Riley currently smokes 20 cigarettes and consumes two 300ml bottles of beer daily. He is strongly advised to quit smoking and reduce alcohol intake.
Mr O’Riley is advised to intake low-fat diet. His regular diet includes sausages, deep fried chips, eggs, MacDonalds, and he is allergic to nuts. He will undergo rehabilitation exercise program with the help of his local physiotherapist.
Mr O’Riley is single and lives alone. He works as a fencing contractor. He is 170cm tall and his weight is 99kg.
Based on the above information, kindly prepare and send a detailed dietary guideline with simple healthy recipes to Mr O’Riley. His residential address is attached to this letter. If you have further queries, please do not hesitate to contact me.
Yours faithfully,
Registered nurse
Lee Wong
(Words count :186)
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