Time allowed: Reading time: 5 minutes
Writing time: 40 minutes
Read the case notes and complete the writing task which follows.
Notes
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 followup care. Stress that Mr Wilson’s case needs urgent attention. In your answer:
expand the relevant case notes into complete sentences
do not use note form
use letter format
The body of the letter should be approximately 180-200 words.
Sample letter by Lifestyle Training Centre
Ms Jennifer Adams,
Elizabeth Community Health Centre,
125 Munno Parra Avenue,
Elizabeth, 5098
24/10/2009
Dear Ms Adams,
Re: Mr Martin Wilson, aged 62 years.
I am writing to refer Mr Wilson who requires your urgent attention and follow-up care, particularly to overcome gambling addiction, following his discharge today. He is currently recuperating from an attempted suicide, overdose of Mogodol.
At present, Mr Wilson is weak, physically unfit and depressed. He is remorseful, ashamed and wants to overcome his addiction; he is under anti-depressants. He suffers from Bronchitis, Psoriasis, Type II diabetes and has poor appetite.
Mr Wilson started gambling 2 years ago, following his retirement, without the knowledge of his family at first. Eventually, he lost his friends as well as a lot of money including superannuation funds, ending up in debt, which led him to depression.
Mr Wilson lives with his wife and son. He heavily smokes as well as drinks alcohol. He used to play lawn bowl.
Based on the above, please provide therapy and help Mr Wilson to recover from his gambling addiction. Actively assist and encourage him to join the Gambling Addiction Action Group in Elizabeth Community Centre as well as to connect with Quitline. Encourage him to take part in social sporting activities such as lawn bowls as well as to continue his anti-depressant medication regimen. He needs the use of wheel chair for another week and walking frame thereafter.
Should you have further queries, please do not hesitate to contact me.
Yours sincerely,
Registered nurse.
(words count: 221)
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