TASK 4: CASE STUDY – NURSES – MR HENRY MCDONALD
Patient History: Born: 23 June 1946
This patient has been in your care and is now going home from hospital
Admitted to hospital: 16 April 2008
To be discharged: 18 April 2008
Suffering from Right side hemiplegia
Patient’s History
Myocardial infarction 5 years ago Takes aspirin for hypercholesterolemia
Episodes of transient loss of vision – L eye
Episodes of clumsiness and weakness – R arm – Usually only for a few seconds. Triggered by exertion
Dribbling saliva. Suffers from expressive aphasia.
No previous cerebrovascular episodes Long term heavy smoker.
Overweight at 115 kg (172 cm) Lives with a partner.
No history of depression, self-harm or other psychiatric illnesses
Note: Verbal consultation with patient’s partner reports he has been unusually depressed since onset of symptoms one month ago.
Nursing notes: Visual acuity in L eye was 6/18.
Evidence of ischemic retinopathy
No other neuro or cardio abnormalities found Color flow Doppler ultrasound of internal carotid arteries show complete Occlusion on L 50% stenosis on R.
CT brain scan – normal Dipyridamole added to treatment.
Hospital nutritionist planned 1000 cal./day diet for patient Pt. shown lip/ tongue exercises. Pt. encouraged to read aloud
Discharge plan: Patient advised to stop smoking, Review progress in one month.
Might need anticoagulation or extracranial/intracranial bypass surgery if symptoms persist Needs to see GP, District Nurse, Speech therapist
Needs to see Psych – counselling re depression? Antidepressants
WRITING TASK: Using the information in the case notes, write a letter of referral to: Dr Austin Williams, Western Medical Centre, 1150 Footscray Road, Sunshine, Victoria 3011, requesting adherence to discharge plan. Give full details of the plan. Write 180-200 wards. Use full sentences.
Submit your OET letters for correction: (for a minimal fee)
https://goltc.in/oet-writing-correction/
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