Maria Joseph OET letter

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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