Writing Task 4: MR HENRY MCDONALD OET LETTER

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.

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