Amber Watson OET letter

TASK 37: Today’s Date: 20th May 2012

You are the Nurse Practitioner at a Women’s Health Clinic in Melbourne. As a Women’s Health Nurse Practitioner, you are responsible for the primary service which means you may request appropriate tests and prescribe certain medications, but you are required to refer complex case to Medical Practitioner. You had 2 recent appointments with the patient, Amber Watson, as follows:

PATIENT DETAILS                        Name   : Amber Watson

Address           : 20 Pixe Street, North Fitzroy, Melbourne. Phone    :( 07) 4567 8910

Date of Birth: 25/03/1993 Marital Status: Single       Next of kin : Janine Watson (Mother)

General Health          No known allergies                 No current medications

No significant medical or surgical history                  Weight: 73 kg; Height 165 cm

BP 125/75; Pulse 76                            No reported recreational drug use      

Commenced smoking in last 9 months, now smokes 10/day.                         Alcohol use on weekend only. Drinks -3 ‘Vodka Cruisers'(premix spirit equivalent to 2 standard drinks each) on a night.

Sexual and Reproductive Health                                On oral contraceptive pill for last 12 months.

Regular menstrual periods each 28 days. LMP 7 days ago.                No previous Pap tests.

No history of STI.                   No pregnancies.

Recently ended monogamous relationship of 10 months and now has a new partner of 2 months- not sure if monogamous. Does not use condoms. Last sexual contact 14 days ago.

Has been immunized for Hepatitis B.

16th May 2012 Amber presented to clinic requesting a Pap test. Pap test suggested by mother. Amber concerned about weight gain of 10 kg over last 12 months and wants to know about other methods of contraception.

Sexual and reproductive health history taken. Partner risk discussed -no IV drug use, no recent overseas travel.

No reports of pain, discharge or irregular bleeding.                           Urine PCR test for Chlamydia collected.

Pelvic exam. Undertaken- NAD                     Pap smear taken

Patient to return in 3-4 days for Chlamydia results. Pap test results in 2-4 weeks.

Safer sexual practices discussed, including barrier protection.           Cervical screening information sheet provided.

Risks of smoking and benefits of quitting discussed with patient.     Referred to Quitline.

Referred to women’s Health nutritionist.

20 May 2012                           Returned for results: PCR test positive for Chlamydia trachomatis.

Patient informed of results.                                                         Arranged notification of partners

Prescribed azithromycin 1 gram as a single dose. Advised not to have sexual contact for 7 days after treatment.

For referral to GP for further testing and contraceptive advice.

WRITING TASK Write a referral letter to the Dr. Jane Thompson, Medical Practitioner at the North Fitzroy General Practice 12 Raeburn, St North Fitzroy 3124, requesting review of your patient to discuss contraceptive options and further testing for sexually transmitted infections and blood borne viruses.

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