TASK 49        Date: 21.05.2014

You are a Neurological Nurse Practitioner in the neurology ward at St. George Hospital

Melbourne where Ms. Jessica White is admitted.

Patient Details           : Jessica White           

Age      : 50 Years

Marital Status           : Divorced                  

Date of admission : 19.05.2014

Past Medical History: Migraine headaches (Ibuprufen 600 mg & Vicodin) Depression (Zoloft 50 mg) No history of Diabetes 2nd, HTN No Known allergies

Social History : Lives with 16 yr old daughter

Retired medical receptionist (25 years) No drug and tobacco

Drinks wine rarely

Family History          : Mother died at age 70 after a heart attack

She had migraine

Maternal grandfather had Stroke at age 69

Medical Background : 6/52: Upper Respiratory tract infection with Rhinorrhea,

Congestion, Sore throat and cough

Denies chills, fever, weight loss, chest pain and joint pain Vitals

T 37.6, BP 128/78, P 85

Present Complaints   : Complaint of blurred vision last day after sitting down to

work on computer for 20 minutes, went to bed and upon waking up next morn.

Double vision noticed

Pt was transferred to hospital ambulance.                 

Experience intermittent pounding blfrontal headaches (8/10) that worsen with straining like coughing or bowel movement.

Had same complaints as a teenager, 4-6 times/year along with photophobia, nausea, vomiting lasting several hours to 2 days, reduced by ibuprofen Vicodin Pt denies head trauma, fever or other neurological symptoms Daughter states that rt eyes seems to be produded in last few days.

Neurological exam    : Alert, attentive & oriented Speech is clear and fluent with

good repetition, comprehension and naming. She recalls 3/3 objects at 5 minutes. CN II: Visual fields are full to confrontation, fundo scopic exam is normal with sharp discs and no vascular changes.

Venous pulsations are present bilateraly, Pupils are 4 mm and briskly reactive to light. Visual acuity is 20/20 bilaterally CN III, IV, VI: At primary gaze, no eye deviation. When the pt is looking to the left, the right eye does not adduct. When the patient is looking up, the right eye does not move up as well as the left. She develops horizontal diplopia in all directions of gaze especially when looking to the left. There is ptosis of the right eye, convergence is inpaired.

Laboratory Data        : CT Scan: no abnormalities

MRI scan: no signal abnormalities in the brain stem or in the corpus callosum. No abnormalities in orbits, or venous structures.

RBS: 10 mmol/L         Diagnosis        : R IIIrd nerve palsy   

Intervention   : CSF analysis for meningitis

HBAIC to evaluate diabetes (recently diagnosed) Close observation for neurological worsening Eye patch for comfort to eliminate diplopia                   Tab Naprosyn 400 mg bd for migraine (Replaces Ibuprofen & Vicodin)

WRITING TASK: Using the information given in the case notes, writes a referral letter to Dr. Michael Bryant,

Neurologist, St. George Hospital, Melbourne for a detailed neurological assessment and treatment.

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