Martin Wilson OET letter

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.

View sample answer by Lifestyle Training Centre

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