All posts by Jomon John

Mr Dallas Walters OET letter

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TASK 76: Mr Dallas Walters is a patient on a renal ward where you are the charge nurse.

Age: 51                                  

Marital status: Married with 2 adult children.

Religion & cultural background: Uniting Church & aboriginal background

Admission Date: 16th June 2011, Charles Gardiner Hospital                      Discharge Date: 22nd June 2011

Diagnosis: Insertion of continuous ambulatory peritoneal dialysis (CAPD) catheter for CRF

Family/Psychosocial: *On Disability Support Pension (DSP) for schizophrenia

*Mental status relatively stable with mild chronic delusions – ‘Aliens are spying on me 24/7’.

*Supportive wife = his carer; has mild intellectual disability

* Live in demountable home in Bunbury Caravan Park        *Pt loves fishing and AFL.

Medical History *Mild CRF for 4 years; recently worsened

*Type 2 diabetes. Stable/compliant with oral meds   *Removal cataract left eye & insertion of intraocular lens

*Quit smoking and drinking 4 years ago – previously heavy for +++ years.

Medications To be forwarded by medical officer

Management and Progress during Hospitalisation:

*Uneventful procedure; catheter inserted successfully

*Prolonged admission as pt and wife slow to learn management of CAPD

*Hyperkalaemic & needed cardiac monitoring for 2/7 But K+ = 4.0 on D/C (N = 3.5-4.8)

*S/B mental health liaison & their Reg. happy that nil acute changes with pt’s psychosis

Discharge Plan: *+++ CAPD /CRF education for pt and wife   

*Monitor for catheter infection or signs of peritonitis

*Important to educate on minimising K+ in diet.                             

*Observe for signs of ↑psychosis & refer prn

*If necessary, get community aboriginal health worker to reinforce CAPD/CRF education

Writing task: Using information provided in the case notes, write a letter of referral to the renal Clinical Nurse Specialist (CNS) at the Bunbury Community Health Centre for ongoing community care of the patient.

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Mr Benjamin OET letter

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TASK –75: Mr Benjamin is a 63 – year-old patient in Care Well Hospital where you are acting as a Charge Nurse.

Patient Details: Marital Status Widower (8 years)

Admission Date 5 September 2009 (Care Well Hospital)

Discharge Date 9 September 2009               

Diagnosis THR – Total Hip Replacement Higher BP

Social Background Lives in Abrina Nursing Home 19-21 Victoria Street ASHFIELD NSW 2131 Had been there for 2 years before coming to Care Well (2 months ago). Has no children; Worked in a bank as an accountant before quiting at age 60 No Pensioner.

Hobbies: reading, writing, chess Brother, Peterson,pay visits daily; No severe signs of dementia are observed yet

Medical Background 2005 – Osteoarthritis requiring total hip replacement surgery

2003 – Blood Pressure (mangaement ongoing)

Medications Aspirin (100mg) Ramipril 5mg

Nursing Management and Progress: Dressing Daily Recommend stretching exercises Follow up FBE and UEC tests                         Assessment Good Condition – post operation

Walks with aid in the beginning but now walks perfectly with wheelie-walker

Appeared disoriented during post operative recovery – possibly anesthetic

Hb dropped (71) post operatively, transfused three units of packed RBCs.Hb normal on discharge (112)

Discharge plan Pain reliever given Panadeine Forte (6tablets / day) Exercise recommended

Equipment required: wheelie-walker, wedge pillow, toilet raiser. Hospital is providing Wheelie-walker and wedge pillow. With help from local medical supplier, raiser hired for 2 weeks.

Writing Task: Using the information in the case notes, write a letter to Ms Susanna Bates, Senior Nurse at Abrina Nursing Home 19-21 Victoria Street ASHFIELD NSW 2131, who will be responsible for Benjamin’s continued care at the Nursing Home.

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Martin Wilson OET letter

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TASK –74: Hospital: Lyell McEwin Hospital         

Patient Details: Name: Martin Wilson Age: 62       

Admission Date: 13 October 2009   

Discharge Date: 24 October 2009

Diagnosis: Attempted suicide – overdose of Mogodol Past Medical History: Heavy smoker (40 cigarettes/day)

Bronchitis (multiple episodes) Underweight – 66kg, BMI 18 Psoriasis

Social History: Retired 2 years ago (bookkeeper with Holden Car Company). Lives with wife, Joan, and adult son in housing trust maisonette in Elizabeth. Wife works at Coles, son unemployed. 2 married daughters and 5 grandchildren. Regular social drinker. Depression related to gambling addiction Began gambling 2 years ago

Has lost a lot of money including superannuation funds and is in debt. Wife and family previously unaware of addiction – very angry but also upset about suicide attempt Patient remorseful and ashamed Wants to overcome addiction. Used to be a keen lawn bowls player Has lost friends as result of gambling

Nursing Management: Weak and depressed. Anti-depressants prescribed – Lovan 200g. BP 130/95 Diagnosed with Type II diabetes. Diabetes education regarding diet and oral medications Wheelchair use from 20/10

Psoriasis on Torso and scalp – Diprosone OV cream 2x/day, Ionil T Shampoo. Poor appetite Physically unfit

Discharge Plan: Encouragement to maintain anti-depressant medication routine as the SSRI is established. Mrs Wilson will help with supervision Monthly follow-up appointments with psychologist Dr Brian Murphy, Lyall McEwen Hospital. Social worker appointment to be made for gambling addiction therapy. Strong encouragement and assistance to join Gambling Addiction Action Group, Elizabeth Community Centre. Contact with Quitline needs to be encouraged. Wheel chair required for another week. Frame advised after this Maintain psoriasis treatment

Maintenance of low GI diet for diabetes – involvement of wife necessary. Encouragement in social sporting activities eg lawn bowls?

Writing Task:  Using the information in the notes, write a letter to the social worker, Ms Jennifer Adams, at the Elizabeth Community Health Centre, 125 Munno Parra Avenue, Elizabeth, 5098 requesting follow- up care. Stress that Mr Wilson’s case needs urgent attention.

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Maria Joseph OET letter

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TASK –73: Patient: Maria Joseph is a 39 years old woman who has been a patient at a hosptical you are working in as a head nurse. Apart from usual childhood illness such as chicken pox, she had been healthy.

10 / 5 2011: Subjective: Frontal headache for 6 hrs. Mild assoc, suffering from nausea, no vomiting, patient with blurred vision but not aura. No other symptoms noticed. She has no family history of migraine.

Objective P96, BP 130/ 70. Normal Cervical Spine Movement, examination normal.

Assessment Probably due to excess tension or personal dilemma

Plan Advised to take rest. Given analgesia (paracetamol (500q4h))

14/5 /2011: Subjective Complained of continuous headaches (left sided and frontal), blurred vision, throbbing headache (left sided). Vomited 5 times during last three hours Complaining of slight paraesthesia.

Objective Distressed, P 103, BP 150/90, Normal peripheral nervous system

Assessment Severe Migraine Possibility

Plan: Stat- Pethidine 100 mg, intramuscular injection Maxolon 10 mg

15 / 5 / 2011: Home Visit: Subjective Fell down at home due to severe left sided headache, started some 5 hrs after reaching home. Injured her right arm, bruises on left leg. slurred speech, half unconscious.

Objective P 100, BP 150/90, extension 4/5 power, left leg knee flexion 4/5

Assessment Probable intracranial pathology, space occupying lesions.

Plan Urgent assessment in Emer. Dept.

Writing task: Using the information given above write a letter to the neurologist, who will attend the patient in the emergency department.

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Mr Lionel Ramamurthy OET letter

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TASK –72: Mr Lionel Ramamurthy, a 63-year-old, is a patient in the medical ward of which you are Charge Nurse.                        

Hospital: Newtown Public Hospital, 41 Main Street, Newtown

Patient details:         

Name: Lionel Ramamurthy (Mr)

Marital status: Widowed – spouse dec. 6 mths 

Residence: Community Retirement Home, Newtown 

Next of kin: Jake, engineer (37, married, 3 children <10)

Sean, teacher (30, married, working overseas, 1 infant)

Admission date: 04 February 2014              

Discharge date: 11 February 2014

Diagnosis: Pneumonia                                  

Past medical history: Osteoarthritis (mainly fingers) – Voltaren

Eyesight ↓ due to cataracts removed 16 mths ago – needs check-up

Social background: Retired school teacher (history, maths). Financially independent. Lonely since wife died. Weight loss – associated with poor diet.

Medical background: Admitted with pneumonia – acute shortness of breath (SOB), inspiratory and expiratory wheezing, persistent cough →chest & abdominal pain), fever, rigors, sleeplessness, generalised ache.

On admission – mobilising with pick-up frame, assist with ADLs

(e.g., showering, dressing, etc.), very weak, ambulating only short distances with increasing shortness of breath on exertion (SOBOE).

Medical progress: Afebrile. Inflammatory markers back to normal. Slow but independent walk & shower/toilet. Dry cough, some chest & abdom. pain. Weight gain post r/v by dietitian.

Nursing management: Encourage oral fluids, proper nutrition.

Ambulant as per physio r/v. Encourage chest physio (deep breathing & coughing exercises). Sitting preferred to lying down to ensure postural drainage.                                                

Assessment: Good progress overall

Discharge plan: Paracetamol if necessary for chest/abdom. pain. Keep warm.

Good nutrition – ↑fluids, eggs, fruit, veg (needs help monitoring diet).

Writing Task: Using the information given in the case notes, write a discharge letter to Ms Georgine Ponsford, Resident Community Nurse at the Community Retirement Home, 103 Light Street, Newtown. This letter will accompany Mr Ramamurthy back to the retirement home upon his discharge tomorrow.

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Harry Kovacs OET letter

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TASK –71: . Harry Kovacs is a 5-year-old boy who is the son of one of your newly referred patients in the community mental health centre where you are a mental health case manager.

Date of birth: 15 April 2006            

Place of birth: Sydney Children’s Hospital, Sydney

School year: Kindergarten                 

Religion & ethnicity: Catholic & both parents Australian born Hungarian

Mother’s name: Elizabeth Kovacs    

Mother’s community admission date: 16 May 2011

Diagnosis: Mother – Major depression with psychotic features Son – ? Early onset separation anxiety disorder

Family/Psychosocial: * Elizabeth suffered PND – depressed since

*She sometimes hears voices calling her and sees ‘men’ running around her house – nil serious psychosis in functional terms.

* Recently 1st psych admission for 6/52after high lethality DSH attempt.

*Harry’s psychological status ok until DSH and hospitalisation; after this +++ signs of separation anxiety

*Father is self employed and works long hours 7/7. Rarely sees Harry & dismissive of Harry’s emotional states, ‘He’s like a bloody girl now!’ he told us.                    *Harry loves soccer and playing with his dog, ‘Rusty’.

Medical History: Eczema; Serous otitis media – required grommets at 18 mths Hearing NAD now.

Medication Nil meds            

Case management care and progress: Elizabeth new to our area (from Parramatta) & referred to us post D/C from Bankstown MH inpatient unit 2/52 ago.

*We will provide her with long term MH case management.

*Harry now 1) cries and panics whenever Mum leaves his sight 2) Socially withdrawn & refusing to attend kindergarten 3) ↑ insomnia & nightmares 4) preoccupied re Mum’s daily activities & that she might leave him again.

  • This is greatly ↑pressure on Elizabeth when her MH is already fragile.
  • Father, John, uninterested in meeting in person or discussing problems in detail.

*Harry attended initial assessment with Elizabeth and separation anxiety behaviour very obvious

Referral plan: * Referral to early childhood mental health team for assessment and management of Harry’s ? early onset separation anxiety disorder.

*Request joint meeting with case manager and Elizabeth.

You are the Case Manager caring for Harry Kovac’s depressed mother but due to his psychological issues need to write a referral for him to John Dyer, Clinical Psychologist on the Bankstown early childhood mental health team at Bankstown Hospital.

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MAVIS BRAMPTON OET letter

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TASK – 70 : Patient: MAVIS BRAMPTON – 72 years old

Admitted: 10 January 2011 To be discharged: 15 January 2011  

Diagnosis: Pleurisy

BACKGROUND: Mrs Brampton has been widowed 25 years. Has been an active member of the community all her life. Is the current President of PROBUS in her area. She with her husband ran the Sydney Road Newsagency until his death at which time she retired.            Attends the local Community Centre three times a week to play Bingo. Has been asmoker all her life (since 18 years of age). Current smoking 10 a day.

NURSING NOTES:

  • 10 Jan 2011 Overweight: BMI 29 Had CXR; IV Amoxycillin with supplementary O2
  • Advised to give up smoking.
  • BP 170/90 Pulse 92 Slightly raised temperature: 39oC Breathless 12 Jan 2011 On low-dairy diet Advised about Nicotine patches.
  • Productive cough – sputum culture done Pravastatin 20mg/day and Celecoxib 100mg/day

13 Jan 2011

  • Deep breathing exercises started. Is keeping to a non-smoking regime.
  • Using Nicotine patches and Zyban (150mg b.i.d).
  • To be discharged 15 Jan 2011.

DISCHARGE PLAN:

  • Support Mrs Brampton – needs monitoring for medication compliance
  • Needs help with nutritious meals (Meals on Wheels) and house keeping (Council Home Help) – Assistance with shopping
  • Monitor her quit-smoking plans – watch for side effects from Zyban such as dry mouth and difficulty in sleeping. If side effects occur Zyban should be stopped. Zyban to be withdrawn after 2 months. Nicotine patches to continue until smoking addiction is under control.

WRITING TASK: Write a letter of referral to Brunswick Family Care Clinic, 44 Decarle Street, Brunswick, Vic 3056 requesting monitoring and ongoing care be arranged for Mrs Brampton. Community Nurse to make sure Mrs Brampton continues her cessation of smoking – with the help of Nicotine patches and Zyban. Zyban tablets to cease as soon as side effects occur (if any). Both Zyban and Nicotine to cease as soon as craving for cigarettes has stopped.

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Alfred Billy OET letter

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TASK – 69     Hospital Royal Perth Hospital          

Patient Details Alfred Billy 52 Years old

Marital status: married           Wife to be contacted if there is any sort of emergency: Maria Jennifer, Arillon City Arcade 207 Murray Street Perth

Admission Date 21/03/2010

Discharge Date 5/05/2010    

Diagnosis Skin cancer – BCC (Basal Cell Carncinoma) (neck) Nodular basal-cell carcinoma

Past Medical No prior hospitalization, no history

History : Nil                           Medications. NIL

Social Truck Driver   

History/Supports Lives with her wife

Habit of consuming liquor for th past 30 years Cigarette Smoker                 Skin dark        

Religion: Protestant

Medical Progress Skin biopsy is taken for pathological study        

BCC – removal of

Pain reliever panadein forte 500mg

Nursing:  No complications noted

Management Perfectly well at the time of discharge No complain of any pain

Discharge Plan Daily obs                 

Medicine to be taken for one more week

Writing Task: You are the charge nurse on the hospital ward where Mr. Alfred Billy has recently had his operation. Using the information provided in the case notes, write a referral letter to the Community Nurse Head at Care Well Hospital, Birmingham, who will be attending to Mr. Alfred Billy, following his discharge.

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Monica Osburn OET letter

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TASK – 68 Ms Osburn is an elderly patient at the Newport Community Health Centre

You are the attending nurse.

Patient details                       

Name: Monica Osburn                      

Age:    69 years

Marital status:           Divorced        

Family:           One daughter (married)

First attended centre:  September 2003                     

Last attended centre: January 2010

Diagnosis:      Hypertension, depression

Social background:   Present: lives alone, rented house in Newport

Moving to rented one-bedroom unit in Woodville close to daughter (daughter’s request)

Income: aged pension. Long history excessive alcohol intake, ↑ when anxious

Medical history: Hypertension (10 years).             

Depression (2 years)

Periodic problems with self-administration of medication

Medications:  Anti-hypertensives and anti-depressants

Nursing management and progress: Regular monitoring by community nurse in Woodville to ascertain medication compliance and alcohol intake

Discharge plan:         Establish contact with medical practitioner after move Monitor medication compliance, alcohol intake and diet Encourage expansion of family social activities – elderly citizens clubs, voluntary groups, etc.

Writing task: Using the information in the case notes write a referral letter to the Community Nurse, Community Health Centre, Woodville, outlining relevant information and requesting continued care

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Mrs Margaret OET letter

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TASK – 67: Maggie Goldstein is a 60-year-old female Alzheimer’s disease sufferer currently admitted to North Caulfield Private Hospital for a dislocated elbow after a fall at her aged care home.

Patient details           

Name: (Mrs) Margaret (Maggie) Goldstein              

Age:    61 years

Marital status:           Married          

Family:           Husband, Solomon (Sol) Goldstein aged 65, no children

Admission date:         8 November 2016                   

Discharge date:          12 November 2016

Admission diagnosis: Dislocated R elbow                 Early dementia; progressing rapidly

Social background:   Full-time care at Eventide Residential Aged Care, 333

Glen Eira Road, Ripponlea, Vic. 3185. Husband lives nearby in Elwood;

Business Owner/Manager “Computers’R’Us”

Previous career and Hobbies: Computer programmer, championship golf

Medical history:        Obesity – Height 157cm/ Weight 90kg, HTN, Alzheimer’s onset detected (11/2014)

– no known Alzheimer’s sufferers in close family

Current condition:    Ready for discharge back into full-time care

R elbow in cuff w sling; healing slowly Skin intact

Uses wheelchair, transfers with some assist Continent of bowel/incontinent of bladder (10/11/2016) Reluctant to wear disposable briefs Requires assist with showers and incontinent care

Medications:  Oxycodone 5 mg 3/day to be continued as needed

Atacand Plus 32/12.5 25mg/day Remeron 15mg/day

Management and progress: Medically stable

Discharge plan:         Spouse will      collect patient when    discharged       to transport back to Eventide. Monitor healing of elbow Monitor incontinence care.

Follow-up w physiotherapist, appt 28/11/2016, 2pm, at Eventide

WRITING TASK: You are Charge Nurse at the hospital where Mrs Goldstein was admitted 3 days ago for treatment of a dislocated elbow. Using the information in the case notes, write a discharge letter to the Supervisor at Eventide Residential Aged Care, 333 Glen Eira Road, Ripponlea, Vic. 3185, for discharge back into permanent full- time care.

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