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 Zyban to be withdrawn after 2 months.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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Aisha Amari OET letter

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TASK – 66 Mrs Aisha Amari is a 75-year-old woman presenting in the clinic in which you work.

Clinic: Westborough Medical Clinic, Westborough 2065

Patient details           

Name: Aisha Amari   

Age:    75       

Residence:      Braybrook

Admission date:         16th of July, 2017                               

Discharge date:          16th of July, 2017

Presenting complaint:Left foot turns out on ambulation. Weak ankle  Ankle pain: chronic – burning sensation

Past medical history:             Mild memory loss       Vision blurry – retinal damage Hypertension – 3 years

Type 2 diabetes – 18 months

Past surgical history:            Cataract surgery (1992)          Appendectomy (circa 1986)

Family history:          Unknown

Diet:                Diabetic                      Low cholesterol          Family brings some meals

Medications:  Self-administered (son calls to remind):         Paracetamol as required Deep heat cream Diabex

Beta blockers                          Calcium channel blockers

Physical review:        5’8″ 63kgs                    Alert and oriented

Hearing and speech are within normal limits Skin intact                   Continent of bowel and bladder

Assessment:   Ambulates / transfers independently No assistive devices in house               No recent falls

Mobile phone with her at all times Pull-cord in bedroom and bathroom

Notes: Speaks only Arabic.

Son (Ahmed) interpreter and information source He is very involved – shopping, errands, finance

Management plan:    Check foot / ankle.

Personal assistance required shower 2d/4h/wk Needs help with dressing

Some household chores and laundry Needs installation of assistive devices

WRITING TASK: Using the information given in the case notes, write a referral letter to home care nurse, Sharon Wilkins, at “Prestige Care”, 393 Victoria Road, Newtown, Braybrook, who will be attending to Mrs Amari at home.

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Mr Walter Pitman OET Letter     

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TASK – 65

You are a nurse in Nurselead Outpatient clinic in Newtown hospital. You taking care of Mr. Pitman

Name of the patient: Mr Walter Pitman          

Age: 69 years          

Family:           Married, has 2 children

Job:     Retired accountant                 

Habits:           No smoking or alcoholism Sedentary lifestyle, no exercise

Past history:  Hypertension since 2008 Overweight

Admission date:         01.07.2018                  

Discharge date:          03.07.2018

PATIENT HISTORY

Present history: Accidental cut injury when using hand saw for cutting wood, referred by family physician for further care. Brought to Newtown hospital with deep lacerations on lower left arm. On admission wound cleaned, sutured and dressed well Prophylactic IV antibiotics starts and course completed

02.07.18          Stopped IV antibiotics. Oral antibiotics started, regular dressings Blood Pressure:  140/90 mmHg (sitting). 180/90 mmHg (supine)

03.07.18   Discharged, advised visits to Nurselead Outpatient clinic

04.07.18  Visited Nurselead Outpatient clinic of same hospital

He had severe pain with mild hematoma: recorded 8/10 on pain scale

Blood Pressure:           186/89 mmHg (sitting)           190/86 mmHg (supine)

06.07.2018 : Wound condition is better, healing, dressing done Blood Pressure:     190/86 mmHg (sitting)196/88 mmHg (supine)

08.07.2018      Wound is healing       

Blood Pressure:           182/80 mmHg (sitting). 194/86 mmHg (supine)

11.07.2018      Wound dressing done, healing well without infection Blood pressure still elevated

14.07.2018: Wound healed well        

Blood Pressure:   190/84 mmHg (sitting)       196/86 mmHg (supine)

Assessment:   BP elevated?? Orthostatic hypertension Plan: Cardiac assessment for hypertension

Family physician referral

Writing Task: Write a referral letter to the family GP Dr Lacricell, Newtown 2137, asking him to do a full cardiac assessment and management of Mr Pitman’s hypertension.

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Mrs. Rose Debham OET letter

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TASK – 64    

Patient’s name:         Mrs. Rose Debham

Date of Birth: 4th July, 1989  

Social History:         

recently married, no smoking or alcohol drinking

Past Medical History:          

previously fit, Migraine diag 5 months ago – another GP

Medication History:  Aspirin & Codeine & Metoclopramide to control migraine

Family history:          mother- hypothyroidism

2/12/2009 Subjective: feeling unwell for 3 months, intermittent fevers and sweats, anorexia Joints & muscles- ache, hands- painful & clumsy with stiffness in mornings for about 1 hour

Objective: looks flushed, Temperature 38.6 degree C, Facial oedema – present, pulse rate- 95/ min, BP- 110/65, Multiple aphthous-like ulcers on buccal mucosa, heart & lungs – normal, spleen – enlarged, hand joints swollen and tender.

Assessment: possibility of autoimmune disease or infections

Plan: Explain the possibilities, confirmatory tests such as urinalysis, blood tests, ESR, C reactive protein, blood culture, antibodies screening, Ibuprofen 400 mg 3 times daily for symptomatic control, review in a week’s time

10/12/2009. Subjective: noticed slight improvement but still has pain in hand joints, no fever, concerned about serious complications of autoimmune diseases

Objective: swelling in hand joints -reduced, temp- normal, urinalysis-trace of protein (0.3g/L), complete blood examination – haemolysis & pancytopenia, ESR- 55mm/hour, C reactive protein – 5 mg/L, Blood Culture – Negative, X ray (hand joints ) – soft tissue swelling & no erosion, CXR- normal, Antinuclear & double stranded DNA antibodies- positive.

Assessment: Systemic lupus erythematosus

Plan: general measures (exercise, avoidance off UV light, screen), continue NSAID (Non-Steroidal Anti-Inflammatory Drug), hydroxycloroquine 200 mg 2 times daily, refer to specialist to assess systemic involvements, regular reviews every month

20/1/2010. Subjective: regular check-up, all symptoms under control, able to cope normal daily activities, arthritis, fever & lethargy -well managed with current medication expressed a strong desire to conceive in near future, use condoms & spermicide for contraception

Objective: all examinations – unremarkable            

Assessment: well-controlled SLE

Plan: Continue current medication to prevent recurrence, Explain the risks to mother & fetus, refer to consultant obstetrician for advice prior to conception

Writing Task: Using the information in the case notes, write a letter of referral to Dr. Stephanie Coleman, Consultant Obstetrician at the Royal Adelaide Hospital, North Terrace, Adelaide SA 5000.

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Kenneth Mason OET letter

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TASK – 63:   You are the charge nurse in the Emergency Department at Newtown Hospital. Read the case notes below and complete the writing tasks which follows.

Patient’s Details:      

Name: Kenneth Mason          

Address:         8 Stuart Street, Perth, WA 6000

DOB:  February 27, 2000

Social Background:  A secondary student studying in Perth University, a varsity football player.

Medical History:  January 2018- Had right femur fracture sustained during one practice.

March 2015- Suffered Concussion after being hit accidentally with a ball

Allergies to Food: nil Previous medications: nil

Date of Admission: 16 June 2018 Presenting Situation:

Chest pain is increasing especially when coughing

Suffered Chest contusion 20 minutes earlier after playing football. Difficulty of breathing

Diagnosis is chest pneumothorax as confirmed by Chest X-ray. Shortness of breath.   

Assessment:   92% Oxygen Saturation

Has nasal Flaring upon inspection (has difficulty in breathing) Restless

Cannot complete sentences when speaking Oriented, knows his name, age and present location

Has peripheral bluish cast/discoloration in the skin and mucous membrane

Chest Palpation: No mass heaving upon palpation

Chest Auscultation: Normal but still has pain Lung Inspection:        Left lung: Normal

Right lung: present air upon entry

Treatment:    Immediate insertion of ICC and connected to water sealed drainage

IV Fluid of 2li/24 hours Morphine 10 mg given IV stat

Monitoring of any bleeding in the ICC May have free fluids and light meals

Care Plan:     Monitor Blood present in the ICC                   Monitor Vital signs until stable

The nurse will accompany patient in ward to report medical history, current situation, treatment plan, etc.

Writing Task:: Using the information in the case notes write a letter to Ms. Angela Coyne the charge nurse in Surgical Ward A, Newtown Public Hospital, 900 Carrington Street to report medical history, current situation, treatment plan, etc.

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Anna Paro OET letter

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TASK 62        MARCH-2018            You are a district nurse (nurse caring patient at homes) taking care of Mrs. Anna Paro, who needs daily dressing for the leg ulcer.

Patient Details:         

Name  : Anna Paro                

Age      : 75 years

Medical History : COPD, Osteoarthritis, Appendoctomy-2009, Suffering with leg ulcer, Taking salbutamol pm, ipratropium 25/250 2 puffs daily

Social History            Lives alone, Husband died      Two children-one native, other overseas

10/03/2018.   Subjective        : SOB increase (especially day activities, not at night), Salbutamol ineffective, Need rest or sit down to hold breath back

Objective        : Comfortable at rest, no sob RR: 18/Mt, BP: 130/80.    Auscultation. Good air entry both sides, little wheeze on left Observed patient’s inhaler use inappropriate

Diagnosis        : SOB worse due to? COPD, inhaler use

Treatment, Ventolin 2 puffs under supervision

Educated about inhaler use with spacer – patient claims “this is not the way my pharmacist told”. Plan. Refer/advise pharmacist re inhaler.

WRITING TASK: Write a referral to Paro’s pharmacist to teach her about inhale

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Steve Gladson OET letter

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TASK 61      You are a registered Nurse in the pediatric isolation ward of Calvary Hospital, Bruce Canberra

Patient Details:         

Name   : Steve Gladson (7 years)      

Mother : Susan Gladson         

DOA   : 9/3/14

Reason for Admission : Complaints of high fever, body pain & headache

Rashes, (water-filled blisters) red colour over face, hands and back

Diagnosis                    Chickenpox (1stattack)          

Physical Examination

Height 47.8”               

Weight 50 pounds                  

V/s Temp 39°C, P/r 90/min Resp 18/min

Family background

Lives with mother, grandma and 2 siblings, Mark (10 years), Julian Good family bonding

Father, Glandson Clark worksabroad

Social Background: School going, very active.

Many friends, best friend – Cathy (she had chicken pox – possible cause of disease transmission)

Psycho-sexual developmental Stage:Latency

Medical History        Frequent fever, cold   

Fever last month – taken treatment Allergic to eggs and tomato

Immunization schedule incomplete (same for all 3 children)

Treatment Plan         Adequate rest and good food              Tab Ibuprufen. 250 mg TID (↓ fever)

Tab Piritone 5mg BID. Increase fluid intake (fresh juice & water) Emollient calamine lotion for rashes and itching

Precautions (family)

Chicken pox highly contagious

Causative organism Varicella Zoster virus Mode of transmission droplets Incubation period – 11 to14 days

Chances of spreading exist till blisters got healed and dried up. Avoid travelling and close contact with neighbours, friends and relatives Vaccinate siblings (if not vaccinated) within 5 days. Parents -take booster vaccination dose

Writing Task: Using the information in the case notes, write an advice letter to the mother of Steve, informing her about the chances of disease transmission and necessary precautions to be taken.

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