Writing Task 4: MR HENRY MCDONALD
MODEL ANSWER BY LTC
Dr Austin Williams,
Western Medical Centre,
1150 Footscray Road, Sunshine,
Victoria 3011
18/04/2008
Dear Dr Williams,
Re: Mr Henry McDonald,
I am writing to refer Mr. McDonald, who requires support in adhering to his discharge plan following his hospitalisation for right-side hemiplegia.
Mr. McDonald had a myocardial infarction 5 years ago and currently takes aspirin for hypercholesterolemia. He experiences transient loss of vision in his left eye, with a visual acuity of 6/18, as well as momentary clumsiness and weakness in his right arm, triggered by exertion. Although ischemic retinopathy was noted, a CT brain scan revealed no other neurological or cardiovascular abnormalities. He has no history of cerebrovascular episodes.
A Color flow Doppler ultrasound of internal carotid revealed complete occlusion on the left and 50% stenosis on the right side. Dipyridamole was added to his medications. Mr McDonald dribbles saliva and suffers from expressive aphasia. He was taught lip and tongue exercises and encouraged to read aloud.
Mr. McDonald is overweight at 115 kg and has been instructed to follow a 1000-calorie diet. He has been unusually depressed for the past month and may need antidepressants and counselling. He is advised to quit smoking.
Based on the above, please assist Mr. McDonald with consultations with a District Nurse, GP, and Speech Therapist. He might also require to undergo anticoagulation or extracranial/ intracranial bypass surgery if symptoms persist. If you have any queries, please contact me.
Yours sincerely,
Registered nurse.
TASK 4: CASE STUDY – NURSES – MR HENRY MCDONALD
Patient History: Born: 23 June 1946
This patient has been in your care and is now going home from hospital
Admitted to hospital: 16 April 2008
To be discharged: 18 April 2008
Suffering from Right side hemiplegia
Patient’s History
Myocardial infarction 5 years ago Takes aspirin for hypercholesterolemia
Episodes of transient loss of vision – L eye
Episodes of clumsiness and weakness – R arm – Usually only for a few seconds. Triggered by exertion
Dribbling saliva. Suffers from expressive aphasia.
No previous cerebrovascular episodes Long term heavy smoker.
Overweight at 115 kg (172 cm) Lives with a partner.
No history of depression, self-harm or other psychiatric illnesses
Note: Verbal consultation with patient’s partner reports he has been unusually depressed since onset of symptoms one month ago.
Nursing notes: Visual acuity in L eye was 6/18.
Evidence of ischemic retinopathy
No other neuro or cardio abnormalities found Color flow Doppler ultrasound of internal carotid arteries show complete Occlusion on L 50% stenosis on R.
CT brain scan – normal Dipyridamole added to treatment.
Hospital nutritionist planned 1000 cal./day diet for patient Pt. shown lip/ tongue exercises. Pt. encouraged to read aloud
Discharge plan: Patient advised to stop smoking, Review progress in one month.
Might need anticoagulation or extracranial/intracranial bypass surgery if symptoms persist Needs to see GP, District Nurse, Speech therapist
Needs to see Psych – counselling re depression? Antidepressants
WRITING TASK: Using the information in the case notes, write a letter of referral to: Dr Austin Williams, Western Medical Centre, 1150 Footscray Road, Sunshine, Victoria 3011, requesting adherence to discharge plan. Give full details of the plan. Write 180-200 wards. Use full sentences.
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