Name           : Joel Silbersher                   

Age      12

Admitted        : 10 September 2008                          

Discharged : 13 September 2008

Reason for admission: Dehydration, weak rapid pulse, orthostatic hypotension, acetone breath, tachycardia, weakness, fatigue, N & V. abdominal cramps

Diagnosis: Diabetic ketoacidosis

History:  IDDM Type 1; Joel was staying with his friends in Ballarat for the weekend; Insulin injections (Self-administered) neglected, increased sweet and fatty food intake; Stress levels were high; embarrassed by condition.

Nursing Notes: IV fluids, IV insulin administration, blood glucose monitoring; electrolyte replacement; K+ replacement. Pt. condition improved gradually with above, maintained consciousness; glucose added to IV when blood glucose normalized.Pt. commenced on low-fat, low-sugar diet

Discharge Plan:  Pt. and family educated re prevention of future episodes, carry medical ID (indicating diabetic, name of GP, type and dose of insulin) at all times, tell friends and family how to respond in case of hypoglycemia; need for complying with dose and self- medication emphasized; diet plans given, exercise options outlined.

Writing Task: Using the information in the case notes, write a letter of referral to historical GP, Dr. Harry Coleman, St. Kilda Health Clinic, 35 Carlisle St, St Kilda 3182. DO NOT use note form in the letter. Expand the relevant case notes into full sentences. The letter should be approximately 200 words long.

Submit your OET letters for correction: (for a minimal fee)
https://goltc.in/oet-writing-correction/