OET Writing 60 Case Notes Mobile Version

CASE NOTES 1.
OCCUPATIONAL ENGLISH TEST

WRITING SUB-TEST: Nursing
TIME ALLOWED: READING TIME: 5 MINUTES |
WRITING TIME: 40 MINUTES
Read the case notes below and complete the
writing task which follows.
NOTES
You are a Nurse Practitioner at the Medical
Center Brisbane.
Patient Details:
Name: Sydney Loten
DOB: August 14, 1946
Address: 5 Peanut Hedge, Carina Heights QLD
Phone: 07 86734214
Next of kin: Eby Simmons (adopted son)
Social History:
Retired Professor; Widow, one adopted son
24-year-old student; Husband died 2014.
Lives with her son in a one-storey house, son
is often unavailable to care for patient due to
school and work.
Oxygen readily accessible at home via nasal
cannula at 2-4L as needed
Medical History:
Height: 160cm Wt. 65kg
Occasional alcoholic beverage drinker. 1-2
bottles of beer/week (till 2019, Jan; 1 bottle of
beer/week (now)
Smoker, 10-15 sticks/day for 35 years (till
2018); 5 e-cigarettes (since then)
No previous or surgical procedures
Diagnosed with COPD in 2010, maintained on
Ipratropium bromide inhaler, 1 puff,
Budesonide
+ Formoterol, 2 puffs BID and Prednisone 40
mg taken as a single daily dose for acute
attacks
Diabetic since 2007, Metformin 500mg BID,
Glipizide 5mg OD
Hypertensive since 2008, Losartan 40mg OD
Patient underwent routine colonoscopy,
multiple polyps found. Admitted at Medical
Center Brisbane on April 11, 2020. Colon
polypectomy on April 13, 2020
Post-op complications at the recovery room,
experienced respiratory distress, Arterial
Blood Gas revealed. Covid19 test negative.
Metabolic acidosis. Transferred to ICU and
moved to regular ward on April 15, 2020
Hooked to oxygen support at 3-5L NP as
needed.
Patient uncooperative at times and requires
encouragement to take medications.
Difficulty in sitting and cannot walk around
the room.
Pain meds given as prn: Paracetamol 1g IV and
Endone 2.5mg PRN for intolerable pain On
laxative, Senna, OD at bedtime.
Was on folly catheter now with adult diaper
due to incontinence.
Stable vital signs at regular ward 02 sat at 96-
97% at 2-3L.Wean if able to tolerate 1L.
Moderate post op pain, wound with no
exudates
Medical Records
April 17, 2020
Patient hesitant to ambulate around her
room.
Prefers to walk with assistance.
Unable to tolerate O2 at 1L. O2 sat at 98% at
2L.
Anxious during wound dressing.
Minimal pain at the incision site. Encouraged
sitting, standing and walking inside her room.
Poor appetite. Constipation, resolves with
laxative.
April 19, 2020
Patient walks around her room with walker.
Can walk along the hospital corridors but
requires increase to 3L O2 after walking. O2 sat
at 98% at rest. Less uneasy during dressing
change. Improved appetite.
April 22, 2020
Patient can walk with a cane. Can tolerate O2
at 1L, O2 sat 98%. Minimal pain at incision site.
Regular bowel movement. Still requires adult
diapers for incontinence. Eager to go home.
Discharge will be facilitated once O2
availability at home is confirmed.
April 23, 2020
Patient is ready for discharge. Home
medications and instructions given in the
presence of her son.
Need for transition care program explained.
Continue dressing change at home.
Advised to monitor O2 consumption. Follow
up check-up scheduled on April 30. 2020.
WRITING TASK
Given the patient’s current situation, you
need to write a formal letter to the Nursing
Director, Jane Hall of Southern Valley
Community Transition Care Program, 64
Gladstone Road, Highgate Hill Qld 4101.
Discuss the need of the patient’s continuity of
care at home.
In your answer:
Expand the relevant notes into complete
sentences
Do not use note form
Use letter format
The body of the letter should be
approximately 180–200 words.
CASE NOTES 1.2

NOTES:
Today's date
10/07/09
Betty Olsen is a resident at the Golden Pond
Retirement Village. She needs urgent
admission to hospital. You are the night nurse
looking after her.
Patient Details
Address: Golden Pond Retirement
Village 83 Waterford Rd,
Annerley, 4101
Phone: (07) 3441 3257
Date of Birth: 29/01/1926
Marital Status: Widowed Country of birth:
Australia Social History:
Moved to Retirement Village following the
death of husband in December 2007.
Next of kin: Son, Nicholas Olsen, 53 Palmer
Street,
Warwick 4370, Ph (07) 4693 6552.
Normally alert and orientated. Enjoys bridge,
bingo and reading.
Medical History
 Hypothyroidism since 1997
 Hypertension since 2003
 Glaucoma since 2004
 Allergic to penicillin
Prescription Medication
 Karvea 150mg 1 daily
 Oroxine 0.1mg 1 daily am
 Timoptol Eye Drops 0.5% 1 drop each eye
am & pm
 Normison 10 mg as required
Nonprescription Medication
 Golden Glow Glucosamine Tablet - 1 with
breakfast for arthritis
 Vitamin C Complex Sustained Release – 1
with breakfast.
Mobility / Aids
Independent with walking stick. Arthritis in
hands. Wears glasses Continence: Requires
continence pad
Recent Nursing Notes
16/05/09
Flu vaccination
29/06/09
Complaining of indigestion following evening
meal. Settled with Mylanta
07/07/09
Unable to sleep – aches in shoulder. Settled
following 2 Panadol and 1 Normison
09/07/09
Requested Mylanta for indigestion, Panadol
for shoulder pain – slept poorly
10/07/09 am
Tired and feeling generally weak. BP 180/95.
Confined to bed. GP called and will visit
11/7/08 after surgery.
10/07/09 pm
Didn’t eat evening meal. Says felt slightly
nauseous. Trouble sleeping, complaining of
shoulder and neck pain. BP 175/95 Given 1
Normison 2 Panadol at 10pm
Rechecked 10.45pm – Distressed, pale and
sweaty, complaining of persistent chest pain,
BP 190/100. Ambulance called and patient
transferred.
WRITING TASK
Write a letter for the admitting doctor of the
Spirit Hospital Emergency Department. Give
the recent history of events and also the
patient’s past medical history and condition.
In your answer:
 Expand the relevant case notes into
complete sentences
 Do not use note form
 Use correct letter format
The body of the letter should not be more
than 200 words.
CASE NOTES 2.1

NOTES:
Shannon Warne, 23, is a university student
who was involved in a car accident three
months previously. He has been in the Royal
Adelaide Hospital for three months and is
ready to be transferred to the Hampstead
Rehabilitation Centre.
Name: Shannon Warne
Age: 23 years
Admitted: April 6, 2007 Discharged: June 14,
2007
Diagnosis:
Broken neck and fractured pelvis. Probable
permanent neurological damage affecting
mobility, speech and memory areas
Social background:
Single. 3rd year architectural studies student
at Adelaide University. Was living in flat but
now needs long term rehabilitation. Parents
living and willing to care for him; may
eventually return home
Currently eligible for disability pension.
Nursing management and progress:
Has made good progress but will need high
level care for some time
Recently started using a wheelchair
Needs daily physiotherapy, hydrotherapy 2x a
week and speech therapy 3x a week Was
suffering bed sores but improving with
increased mobility
Frequent headaches Nurofen 200g max 4x a
day
Discharge plan:
Depression needs to be treated with activities
and interests; likes reading & writing
Contact university for possible continuation of
studies externally
Needs contact with people his own age –
community access?
No special dietary requirements
WRITING TASK
Write a letter to Su Yin Lee, Sister in Charge,
Hampstead Rehabilitation Centre, 695
Hampstead Road, Greenacres 5029.
In your answer:
sentences
Use letter format
CASE NOTES 2.2

NOTES:
Today's Date
01/08/09
You are Sarina Chai, a registered nurse at the
Royal Brisbane and Women’s Hospital
(RBWH). Maeve Greerson is a patient in your
care.
Patient Details
Name: Maeve Greerson
Address: Unit 6, 45 Walter St, Holland Park
4121
Phone: (07) 3942 1658
Date of Birth: 9 October 1951 Country of
birth: Australia
Social History:
Widowed, no children.
Next of kin: Brian Hewson (brother) 67 Bridge
Street, Toowoomba Ph (07) 4693 6558. Family
and patient have requested no further
treatments be used, other than those
necessary to maintain comfort and dignity and
to relieve pain.
Medical History:
March 2009: Laparotomy. Found to have
cancer of the lower intestine with wide spread
metastases. Partial bowel resection and
colostomy performed.
April 2009: 6 weeks radiation therapy for
relief of symptoms.
Prognosis: Not expected to survive more than
3 – 4 months.
24/07/09
Admitted to RBWH following collapse at
home. Dehydration, nausea, severe pain IV
fluids commenced - transdermal patch for
pain, light low fibre foods only.
25/07/09.
Nausea less severe – tolerating jelly, low fat
yoghurt
Occasional break through pain – pain
medication increased Severe oedema of
ankles and lower legs, bladder incontinence.
Does not feel she will recover sufficiently to
leave hospital. Requests visit from Social
Worker
28/07/09
Generally pain free, very weak and
disorientated at times. Rejecting solids but
able to tolerate fluids
- requests apple juice and lemonade.
Social Worker contacted brother. Advises
place
available at Glen Haven Hospice in
Toowoomba from 1 August 2008.
01/08/09
Transferred via ambulance to Glen Haven
Hospice
WRITING TASK
Using the information in the case notes, write
a letter to the Director of Nursing, Glen Haven
Palliative Care Hospice, 971 Arthur Street,
Toowoomba, introducing this patient. Using
the relevant case notes, give her background,
medical history and treatment required.
In your answer:
sentences
Use letter format
CASE NOTES 3.1

NOTES:
You are a Maternal and Child Health Nurse
working at the Romaville Community Child
Health Service.
Today’s date: 15 January 2012
Patient History:
Baby boy: Dylan Charles
DOB: 04/12/11
Born: Romaville Maternity Hospital
First baby of Raymond and Sylvia Charles
Address: 19 Mayfield St, Romaville Discharged
8/12/11
Family History:
Mother: Aged 24 First Child
Father: Aged 25 Soldier Currently away from
home on duty
Birth History:
Normal vaginal birth at term
Birth weight: 3400gm
Apgar score at 5 min: 9
No antenatal or postnatal complications
15/01/12 Subjective
Silvia and baby attended for routine 6 week
check-up. Silvia says she is concerned about
constipation: once every three days, hard
stool. Mother is asking about stool softener or
prune juice for baby.
Breast fed for first three weeks after birth. •
Baby became unsettled during summer
heatwave in December.
Silvia got sick and had a fever for a few days.
Mother-in-law (Mary Charles) came to visit
and advised changing baby to formula feeds.
Mary advised extra powder in formula feeds
to improve weight gain.
Silvia worried she does not have enough
breast milk and now gives extra formula feeds
as well as breast feeding. Dylan difficult to
bottle feed.
Silvia wishes to breast feed properly as she
believes it would be the best thing for her son.
Mary Charles plans to stay with the family for
at least a further month to help with baby.
Tensions developing between mother and
mother-in-law over what is best feeding
method for Dylan.
Objective:
Reflexes normal
Slightly lethargic
No abdominal tenderness
Heart Rate: 174
Respirations: 56
Temperature: 37.1
Weight: 4200gms
3 wet nappies in last 24 hours
Urine dark Assessment:
Mild constipation and dehydration Plan:
Increase breast feeds
Refer to breast feeding support service
Check formula is correctly prepared
If continuing formula feeds, advise to
supplement with water (boiled and cooled)
Advise on keeping baby cool in hot weather
Return for review in 48 hours.
WRITING TASK
Please write a referral letter to the Lactation
Consultant at the Breast Feeding Support
Centre, 68 Main Street, Romaville.
In your answer:
sentences
Use letter format
CASE NOTES 3.2

NOTES:
Today's Date
09/09/09
You are Lee Wong a registered nurse in the
Coronary Care Unit, St Andrews Hospital
Brisbane. Bill O’Riley is a patient in your care.
Patient Details
Name: Bill O’Riley
DOB 12 January 1956
Address 9476 Old Dam Road, Goondiwindi
Q4390
Next of Kin Brother, Ernie O’Riley 72 Burke St,
Cunnamulla Q4490
Admitted 2 September 2009
Diagnosis: Obstructive coronary artery disease
Operation Coronary artery bypass grafts (x 4)
on 4th September 2008 Social History
Never married
Lives alone in own home just outside
Goondiwindi
Fencing contractor
Medical History
Smokes 20 cigarettes/day
Alcohol: 2 x 300ml bottles beer / day
Ht 170cm Wt 99kg
Usual diet: sausages, deep fried chips, eggs,
MacDonalds
Allergic reaction to nuts
Nursing Management and Progress
Routine post-operative recovery
Advised to cease smoking, reduce alcohol
Low fat diet
Walking well
Wounds healing well
Routine visit from Social Worker
Discharge Plan
Returning Home to Goondiwindi
Appointment made for follow up visit to local
GP Dr. Avril Jensen 2pm 15/9/09
Local physiotherapist to continue
rehabilitation exercise program
Writing Task
Mr O’Riley has requested advice on low fat
dietary guidelines and healthy simple recipes.
Write a letter to the Community Information
Section of the Heart Foundation, Gregory
Terrace, Brisbane on the patient's behalf. Use
the relevant case notes to explain Mr O’Riley’s
situation and the information he needs.
Include Medical History, Body Mass Index and
lifestyle.
Information should be sent to his home
address.
In your answer:
sentences
Use letter format
CASE NOTES 4.1

NOTES:
Ms Nicole Smith is an 18 year old woman who
has just given birth to her first child at the
Spirit Mothers’ Hospital in Brisbane. You are
the nurse looking after her.
Patient Details
Address: Flat 4, Matthews Street, West End
4101
Phone: (07) 3441 3257
Date of Birth: 4 September 1991
Admitted: 9th September 2009
Discharged: 13th September 2009
Marital Status: Single
Country of birth: Australia
Social Background
Nicole is single and has had no contact with
father of child for six months.
She does not know His current address.
No family members in Brisbane. Parents and
sister live in Rock Hampton. Does not
currently have contact with them.
Lives in a rental share flat with one other
woman.
Currently receives sole parent benefits.
Feels very isolated and insecure.
Doubts her ability to be a good mother and
has talked about offering the baby for
adoption.
Medical History
General health good
Had Appendicectomy at 15 years
Non-smoker
No alcohol or illicit drug use.
No drug or other allergies
Obstetric History
First pregnancy
Attended for first antenatal visit at 16 weeks
gestation.
8 antenatal visits in total.
No antenatal complications.
Birth details
Presented to hospital at 1900hrs on 9th
September
Contracting 1:10mins
1st stage of labour: 16 hrs
Mode of delivery: Emergency Caesarean
Section
Reason: Fetal distress and failure to progress.
Baby Details
DOB: 10th September 2009
Time: 1120hrs
Sex: Male
Weight: 4.4 kg
Apgar Score: 6 at 1 min, 9 at 5 mins
Resuscitation: O2 only for few minutes
Postnatal Progress
Maternal post-partum haemorrhage of
800mls
Blood loss now minimal
Wound: Clean and dry
Haemoglobin on 12/09/08: 90 g/L
Started on Fefol (Iron supplement) and
Vitamin C
Started breast feeding but not confident.
Prefers to change to bottle feeding.
Not confident in bathing and caring for baby
Baby weight at discharge: 4.1 kg
Feeding well
No jaundice
WRITING TASK
a letter to The Director, Community Child
Health Service, 41 Vulture Street, West End,
Brisbane 4101 requesting a home visit to
provide advice And assistance for Nicole and
her baby.
In your answer:
sentences
Use letter format
CASE NOTES 5.1

NOTES:
Mrs Pamela Viduka is a72 years old patient in
your care. She is now ready for discharge. She
has just undergo a mitral valve replacement.
Name: Mrs Pamela Viduka
Age: 72 years
Admitted 18/11/2008
Diagnosis: Valvular heart disease (Mitral valve
prolapse)
Reason for admission: fainting, light-
headedness, chest pain
Social history:
Lives with daughter, no longer drives, Widow,
enjoys reading/ doing crosswords, chatty,
friendly, smokers for 55 years.
Medical history:
Chronic bronchitis
Hypertension (150/100)
Chest infections since retirement 12 years ago
18/11/08 admitted
Valve replacement
Antibiotics/anti coagulant therapy
Analgesics
Prescribed Warfarin BID
19/11/08
Patient put on low salt diet
Wear contact lenses
Showering /dressing with help of nurses
Slowly recovering from analgesics
Able to walk/ stand-short periods of time
20/11/08
Recovered from analgesia
Showering and dressing with help of nurses
Pt educated about causes/
preventions of infections
21/11/08
Pt advised to quit smoking/ given tips incl
using patches
Pt was seen by dietician re low salt diet
Able to walk for longer periods of times with
walking stick
22/11/08
Pt recovery well
Can now shower/ dress independently
Still using walking stick/ frame
Pt advised of discharge on 24/11/08
Vital signs unremarkable
24/11/08
Pt told of discharge plan?
Discharged
Discharge plan:
Needs to rest
Requires home help- to be visited by district
nurse
Patient to monitor medication usage
Regular follow-up examinations
INR- to be checked on regular basis
Avoid invasive surgical or diagnostic
procedures until prophylactic antibiotics are
given
Auscultatory assessment of heart Current
medication:
Warfarin (anti coagulation therapy)
Salpetrol 3 puff daily Mirax 25 mg daily
WRITING TASK
Using the information in the case note, write a
letter of referral to Maxine Mullins (district
nurse), who will provide follow up care in this
case. Ms Maxine Mullins, 45 Finders Lane,
Melbourne, 300 In your answer:
sentences
Use letter format
CASE NOTES 5.2

TIME ALLOWED: READING TIME: 5
MINUTES
NOTES:
Mrs. Anita Ramamurthy, a 59-year-old
woman, is a patient in the (IPD) In- patient-
department of a hospital in which you are
charge nurse.
Hospital: Sydney Women’s Hospital
Patient details
Marital Status: Married
Height: 5’4”
Weight: 87 kg
BMI:
33 –Obese
Address for correspondence:
#648, Bourke Street, Sydney
Admitted: 18/06/2017
Date of discharge: 23/06/2017
Diagnosis: Acute appendicitis with
Appendicular lump
Treatment: Conservative management

with IV antibiotics
(Planned for interval appendectomy in 6 wks)
Social Background: Businesswoman
(Education Consultant) – Hectic
life, travels a lot due to work
Lives with her husband, Mr. Krishnan
Ramamurthy
Two daughters both married.
Elder daughter stays in Sydney – about three
hours away, works as an Entrepreneur;
younger daughter in Canada, works as a
dentist
Husband is the primary caregiver, elder
daughter visits with husband once an year,
Scared of hospitalization, prone to anxiety
related to this Fond of eating out, rarely cooks
at home, sedentary lifestyle, complains of no
time to exercise due to work, does not drink
or smoke
Diet: Whole Milk, Ice-cream shakes, Fruit
drinks,
Doughnuts, Pancakes, Waffles, Pizzas,
Cheeseburgers, Biscuits, muffins, Cajun Fries,
Hash brown
Medical Background: Known case of
Essential Hypertension (2014) and Diabetes
Mellitus type-2 (2010) (not compliant with
diabetic medication)
Admission Diagnosis: Complaints of pain in
abdomen in right iliac fossa since 17/06/2017
Pain was sudden in onset, acute in nature and
was non-radiating fever
(documented up to 101-degree F), aversion to
food, evaluated outside where USG Abdomen
revealed Acute Appendicitis, admitted for
further evaluation and management
Physical Examination: Conscious, oriented,
No pallor, no icterus, No
Clubbing, No Lymphadenopathy, no pedal
oedema
BP: 126/84, Temp-afebrile, Pulse- 72/min, RR-
22/min SP O2 98%, CNS-NAD, Chest- Bilateral
entry equal, No added sounds
Nursing Management and Progress:
18/06/2017 - Abdomen CT (plain) 18/06/2017
-acute appendicitis with hypodense area in
the region of base of appendix at its
attachment with caecum? Phlegmonous
collection. Possibility of sealed perforation
cannot be ruled out; total leucocyte count -
21,000/cumm
I/V Fluids, broad spectrum antibiotics
(Imipenem), PPI, Analgesics, antipyretics,
other supportive treatment (6/6), Regular
Blood Sugar Monitoring (6/6)
19/06/2017- TLC- 18,000/cumm; complaints
of considerable pain in abdomen, headache,
sips of water, extremely distressed,
constipation, unable to pass gas
20/06/2017- TLC- 14,000/cumm; complaints
of insomnia, headache, tenderness in
abdomen, weakness, tolerating sips of
coconut water and tea
21/06/2017-TLC- 11,000/cumm; tolerating
soft diet, can ambulate with assistance,
complained of weakness, Rev. Dietician re
diabetic diet
22/06/2017- TLC – 8,000/cumm, able to
ambulate slowly, independent with ADL’s
23/06/2017 Pt. stable, accepting orally well,
adequate urine output, TLC showing
improving trend, Pt. stable, Rev.
Endocrinologist – regular chart BSL, INJ
Human Mixtard Subcutaneously bd (12 hrly) 8
units (1 wk.) AC Breakfast and 6 units AC
dinner
Assessment:
Pt. stable with plan for interval appendectomy
(6 wks)
Medications:
TAB Dolo(Paracetamol) 650 mg, t.i.d. (8 hrly)
for 3 days then PRN
TAB Pantocid(Pantoprazole) 40 mg mane for
10 days
Tab Tenorid 25 mg (Atenolol) mane
Tab Supradyn(multivitamin) mane, Tab
Farobact 200 b.d.
Discharge Plan: Avoid strenuous
activities/Travel
Advised to lose weight (exercise program to
start after appendectomy)
Normal Diabetic diet and low-fat diet – Pt.
requests more information, esp. simple
recipes that can be easily prepared at home
Monitoring of fasting and postprandial blood
sugars (present chart during Follow-up
consultation)
Follow up in OPD on 30/06/2017 at 3PM.
Husband advised to contact us immediately in
case of persistent high grade
Fever/pain (at 03492250);
Pt. concerned re monitoring of blood glucose
levels and insulin injections
Husband requests home visit for
demonstration
WRITING TASK 1 1
Using the information given in the case notes,
write a referral letter to Ms. Prabha, Shrishti
Nursing Home Care Agency, Sydney,
requesting a home visit to provide instructions
on self-monitoring of blood glucose levels and
administering insulin injections following Mrs.
Ramamurthy’s discharge.
In your answer
Expand the relevant case notes into complete
sentences
Use letter format
WRITING TASK 2
The patient has requested advice on simple
recipes for low-fat diabetic diet.
Write a letter to Ms. April, Dietician, 258,
George Street, Sydney on the patient’s behalf.
Use the relevant case notes to explain Ms.
Ramamurthy’s condition and information he
needs. Include medical history, BMI, and
lifestyle. Information should be sent to her
home address.
 In your answer
complete sentences
 Use letter format
WRITING TASK 3
Using the information provided in the case
notes, write a letter detailing the post-
discharge care required for the patient to the
patient’s husband, Mr. Krishnan Ramamurthy,
#648, Bourke Street, Sydney.
In your answer
complete sentences
CASE NOTES 6.1

NOTES:
You are a ward nurse in the cardiac unit of
Greenville Public Hospital. Your patient, Ms
Martin, is due to be discharged tomorrow.
Patient: Ms Margaret Helen Martin
Address: 23 Third Avenue, Greenville
Age: 81 years old (DOB: 23 July 1935)
Admission date: 15 July 2017 Social/ family
background:
Never married, no children
Lives in own house in Greenville
Financially independent
Three siblings (all unwell) and five nieces/
nephews living in greater Greenville area
Contact with family intermittent
No longer drives
Has “meals on wheels” (meal delivery service
for elderly) - Mon-Fri (lunch and dinner)
orders meals for weekends
Diagnosis: Coronary Artery disease (CAD),
angina
Treatment: Angioplasty (repeat- first 2008)
Discharge date: 16 July 2017, pending
cardiologist’s report.
Medical information:
Coeliac disease
Angioplasty 2008
Anxious about health – tends to focus on
health problems
Coronary artery disease - saprin, clopidogrel
(Plavix)
HTN metoprolol (Betaloc), Ramipril (Tritace)
Hypercholesterolemia (8.3) atorvastatin
(Lipitor)
Overweight (BMI 29.5)
Sedentary (orders groceries over phone to be
delivered, neighbour walks dog)
Family history of coronary heart disease
(mother, 2 of 3 brothers)
Hearing loss wears hearing aid
Nursing management and progress during
hospital stay:
Routine post-op recovery
Tolerating light diet and fluids
Bruising at catheter insertion site, no signs of
infection/ bleeding noted post procedure
Pt anxious about return home, not sure
whether she well cope
Discharge Plan: Dietary
Low-calorie, high-protein, low-cholesterol,
gluten-free diet (supervised by dietician,
referred by Dr)
Frequent small meals or snacks o Drink plenty
of fluids Physiotherapy
Daily light exercise (eg., 15 minute walk,
exercise plan monitored by physiotherapist)
No heavy lifting for 12 weeks
Other
Monitor would site for bruising or infection o
Monitor adherence to medication regime o
Arrange regular family visits to monitor
progress
Anticipated needs of pt:
Need home visits from community health/
district nurse- monitor adherence to
postoperative medication, exercise, dietary
regime
Regular monitoring by DR., dietician,
physiotherapist
? Danger of social isolation (infrequent family
support)
WRITING TASK
Using the information in the case notes,
writing a letter to the Nursing- in- Charge of
the district Nursing Service outlining Ms
Martin’s situation and anticipated needs
following her return home tomorrow. Address
the letter to Nurse- in- Charge, District Nursing
Service, Greenville Community Health Care
Centre, 88 Highton Road, Greenville.
In your answer:
sentences
Use letter format
CASE NOTES 6.2

MINUTES
NOTES:
Mr. Tej Singh is a 41 years old man who has
been a patient at a clinic you are working in as
a head nurse. Today’s date: 31/01/2017
Name Mr. Tej Singh Randhawa
DOB 09/09/1976
Address 28, Raymond Street,
Romaville
Medical History Hypothyroidism -
thyroid replacement No history of trauma or
weight loss Hospitalized (2010) due to
appendicitis
No POHx
 No allergies
 Immunizations are current
 Smoker (Cigarettes & Cigars)
 Teetotaler
Social History
10/01/2017
Works as a Systems Analyst
Arrived in Australia from India with wife in
2012 as a permanent resident Lives in own
home
Married- wife Mona Randhawa aged 37 1
daughter
Subjective Headache, right-sided, no
cough
no dizziness, denied vomiting and nausea
HA accompanied with significant nasal
discharge
Objective P 96, BP 130/70, T 101.0 f,
neuro exam normal, neck supple Alert, well-
nourished, well developed man
General Assessment Infectious sinusitis
Plan
24/01/2017
Given Augmentin (Amoxicillin/clavulanic acid)
Subjective Complaints of severe
headaches (HA), right- sided,
throbbing, radiating to right eye, teeth, and
jaw lasting 15 mins to < 2 hrs, persistent
HA intermittent episodes, pt. described pain
as
“like someone has put red hot poker in my
head” Pain so severe (10/10) that pt. unable
to stand still,
Sit down or go to bed, no effect when
light/noise avoided rhinorrhoea, no nausea,
no vomiting
Objective P 105, BP 150/90, Physical &
Neuro exam normal, neck tender-right side
Assessment Cluster Headache
Plan
29/01/2017 Given acetaminophen and
non-steroidal anti- inflammatory
Subjective Pt. accompanied by wife,
Mona
Previous complaints of severe headaches-
occurring in episodic attacks associated with
rhinorrhoea and epiphora
Right eye “Droopy” and sometimes as
“sunken” eyelids, first Noted by Mona 1 day
ago, facial flushing before and during HA
Objective Right eye upper eyelid
drooping, Constriction of pupil right eye in
dark lighting, decreased
sweating on right side of face
P 95 BP 130/85
Assessment possibility of? Horner’s
syndrome
Referral plan Referral to ophthalmologist
for further evaluation and management
WRITING TASK
write a referral letter to Dr
John Dyer, an ophthalmologist at West
Suburban Eye Care Centre, 396 Remington
Boulevard, Suite 340, Romaville requesting
him to look into this case.
In your answer:
 Expand the relevant notes into complete
sentences
CASE NOTES 7.1

NOTES:
You are a community nurse working in the
Department of Public Health and Awareness
camp, in Melbourne, Australia.
Background:
Ebola is an infectious fetal disease marked by
fever and sever internal bleeding spread
through contact with infected body fluids by a
filo virus (Ebola virus),whose normal host
species is unknown.
The spread of Ebola and its fatality has
threatened Australian cities and the
government has started awareness campaigns
to for the safety of local people.
Ebola—case contacts:
Any person having been exposed to a suspect,
probably or confirmed case of Ebola in at least
one of the following ways.
Has slept in the same household with a case
Has had direct physical contact with the case
(alive or dead) during the illness
Has had direct physical contact with the
(dead) case at the funeral
Has touched his/her body or body fluids
during the illness
Has touched his/her clothes or linens
Has been breastfed by the patient (baby)
Provided that this exposure has taken place
less than 21 days before the identification as a
contact by surveillance teams.
Contact of dead or sick animals:
Any person having been exposed to a sick or
dead animal in at least one of the following
ways:
Has had direct physical contact with the
animal
Has had direct contact with the animal’s blood
or body fluids
Has eaten raw bush-meat
Ebola
Laboratory contacts:
Any person having been exposed to biological
material in a laboratory in at least one of the
following ways:
has had direct contact with specimens
collected from suspected Ebola patients
has had direct contact with specimens
collected from suspected Ebola animal cases
Provided that this exposure has taken place
less than 21 days before the identification as a
contact by surveillance teams
WRITING TASK
Using the information given above, write a
letter to Mr. Jerome Ray, Social Worker,
Peaceway Suburban Health Clinic to conduct
an awareness class for a group of Melbourne
residents many of whom work with the airline
industry In your answer:
sentences
Use letter format
CASE NOTES 7.2

MINUTES
NOTES:
Your name is Diana Jones. You are the charge
nurse on the medical ward where Mrs. Davies
was admitted as a patient.
Hospital
Patient details Prince Wales Hospital
Name Nina Davies
Sex Female
Date of Birth 25/12/1943
Address 95, Eagle Vale Sydney
Occupation Retired Librarian
Race Caucasian
Marital Status Married
Next of Kin Thomas Davies, John Davies
Family Hx Mother died at 40 - Cancer,
Father died at 57 - coronary
Heart disease, has 2 siblings, brother aged 79
with CAD, twin sister with osteoporosis and
depression
Social History/ Lives with husband in own
house. Home has 2
stories, 2 steps to entrance,
Supports full bath on second floor only, 2
grown children living nearby
Pt. is very active; walks 1-2 miles/day, stopped
smoking 30 years ago
Diet Occasional drink, drinks a cup of
coffee a day, reports diarrhoea and gas with
dairy products
Allergies NKDA
Past Medical Diagnosed with osteoporosis -
first signs noted in
2015
History Mild hyperlipidaemia, Mild
hypertension,
Coronary artery disease,
Tendonitis of R. Shoulder, PTCA, 2009, without
recurrence
Medications Simvastatin (Zocor) 20 mg.
daily
Aspiring daily – pain in ribs and back
Furosemide (Lasix) 10 mg. daily
Alendronate (Fosamax) 10 mg. daily
Calcium + Vit. D 600 mg. daily Vit. E, Vit. C, Mg
Date of admission 28/6/2017
Date of discharge 02/07/2017
Chief Complaint Injury on the left hip -
had a fall after slipping
Dx Fractured L NOF
Nursing Management And Progress
28/06/2017 Admitted through ER, medical
evaluation found
her a good candidate for Left
Hemiarthroplasty;
Post-opt: IV Fluids at 100 cc/hr,
morphine 10 mg IM q. 4 hours as needed for
pain,
IV famotidine (Pepcid) 20 mg. every 12 hours
due to GI distress postop,
cefazolin (Ancef) 1 g. IV q. 8 h. X 3 doses
29/06/2017 Complaints of hip and back
pain,
Pt. restless and confused with hallucinations-
possibly due to morphine
Doctor discontinued IM morphine, replaced
with hydrocodone/acetaminophen 5 mg./325
mg. (Lortab) 1 or 2 q. 4 to 6 hours as needed
for pain.
IV famotidine (Pepcid) switched to oral route
Aspirin and furosemide restarted
30/06/2017 PT (physiotherapy) started,
complaints of dizziness and light-headedness
almost resulting in
a fall
Found to be hypotensive- diuretic (furosemide
discontinued)
01/07/2017 PT continued
Complaining of constipation- not had a bowel
movement since surgery
Docusate 100 mg. daily
Can ambulate short distances with a walker
Assistance with ADL’s
02/07/2017 Original dressing changed;
Ready for discharge
Discharge plan LLE (Left lower extremity) wt.
bearing limited to 30 % for next 6 weeks
Elderly husband not able to care for her; home
not set up for a walker
Neither of children can take her in their
homes- lack of space, too many Stairs, and
working spouses.
Decision is made to transfer her to Helping
Hand rehabilitation centre near her house
Continue Physio program and medication
Assistance with ADL
Staples to be removed on day 14
Dressings to remain dry & intact
Discharge medications:
Hydrocodone/acetaminophen 5
mg./325 mg.
(Lortab) 1 to 2 q. 4 to 6 hours
prn pain
Acetaminophen 325 mg. 1 to 2 q. 4 to 6 hours
prn
headache or minor pain
Famotidine (Pepcid) 20 mg. b.i.d.
Docusate 100 mg. daily
Alendronate 10 mg. daily
WRITING TASK
a referral letter to the Ms.
Susan Parry, Charge Nurse at Helping Hand
Rehabilitation centre, Eagle Vale, Sydney,
NSW where Mrs. Davies will be discharged to
from your ward.
In your answer
Expand the relevant case notes into answers
Use letter format
CASE NOTES 8.1

NOTES:
Ms. Amy Vineyard is a patient in your care at
the St Kilda Women’s Refuge Centre. She is 6
weeks pregnant with her first child. She
presented two days ago, requesting help for
her substance abuse problems. She reports a
desire to reduce or cease her alcohol
consumption and a desire to reduce a cease
her drug use. No desire has been indicated to
decrease or stop cigarette use. She now
wishes to be discharged but will require
ongoing support throughout her pregnancy.
Name: Ms. Amy Vineyard
Age:21
Admission: 6/1/09
Diagnosis: pregnant substance abuse
Discharge: 8/1/09
Plan:
Community mental Health Nursing required
daily next 2 weeks minimum.
Pt wishes to continue living with a friend on
her sofa.
Psychiatric support needed for depression.
Methadone program Alcoholics Anonymous
meetings
1 Trimester Ultrasound at 2 weeks;
maternal health clinic appointment
needed.
Reason for admission:
Pt. self admitted due to concern about
pregnancy. Confirmed pregnancy test the days
before (5/1/09)
Reported pain in lower back
weight loss (6kg over 2 months)
some memory loss
tingling in feet, difficulty sleeping, excessive
worry and hallucinations
feeling depressed-history of depression
no pain in hips or joints
no decrease in appetite
no double vision
Treatment
pt. monitored and blood tests for HIV/AIDS
and STDs
counselled re nutrition and pregnancy
counseled re HIV/AIDS and STDs risk
discussed possibility of rehabilitation clinic for
‘driving out’ – drying out Counselling has been
recommended for appropriate nutrition
during pregnancy, in addition to the possibility
of attending a rehab clinic to address her
alcohol and drug issues Lifestyle:
Nicotine daily 30-40 cigarettes
started smoking at 15 y. o.
Drugs used cannabis, amphetamines, cocaine,
heroin started all above at 16 y. o.
injects heroin, occasionally shares infecting
equipment
Alcohol units/day max. units/day- 15
started drinking at 16 y. o.
lives with a friend, Sophie, on her sofa.
no contact with parents
History: IN THE OPENING OF THE LETTER
Suicidal thoughts, self-harm in past.
Never seen a psychiatrist
WRITING TASK
Using the notes, write a letter about Ms.
Vineyard’s situation and history to new
community health nurse. Address your letter
to Ms. Lucy Wan, Registered Nurse,
Community Health Centre, St Kilda.
In your answer:
sentences
Use letter format
CASE NOTES 8.2

MINUTES
NOTES:
You are Ramona Decosta, a senior nurse
working with Helpline Hospital.
Patient name: Tom Clarke
DOB: 21/09/1954
Address: 92 Lygon Street Carlton
Melbourne
Phone: 0422-894-896
Social Background: Married, Wife-
Miranda Clarke, aged 58 years.
Lives together
Retired – Police officer
Two daughters- elder daughter works in
Sydney, younger daughter – Adelaide
Quite active
Medical History: Hypertension – 1985
Did not seek treatment till 2000; now
managed
with Ramipril GERD -1999
Surgical history: R Ankle dislocation
surgery following a car accident- 1982,
hospitalized for 3 weeks Septoplasty - 1985
Surgery for Anal Fistula - 1992
Eye replacement lens surgery -2007
Hobbies: Cycling, watching movies,
sports, reading, travelling, playing golf and
Tennis
26/08/2016
Accident with a motorbike while cycling,
claimed he was going at a moderate speed, a
motorbike hit him while overtaking, he landed
on the left side of his body
FOOSH (Fall on outstretched hand) injury to L
elbow, presented to ER, limited range of
motion and extreme pain
X-RAY– Nondisplaced fracture of the coronoid
process of the ulna, marrow oedema head
and neck of radius involving articular surface,
moderate joint effusion
Treatment – Sling to keep the elbow
immobilized- 6 weeks, Capsule CM Plus,
Panadol, Ibuprofen, hot compress for pain and
inflammation • Next Appointment in 6 weeks’
time
06/10/2016
 X-ray – injury healing well
 Tab D gain qw
 Tab CM Plus – qd
 Sling taken off
 Exercise program - at home
01/11/2016
Pt. complains of stiffness and limited range of
motion in the elbow
Arrange home visits by physiotherapist for
rehab program
Tab D gain -qw
Tab CM plus- qd
Follow-up appointment- 15/12/2016
WRITING TASK
Write a referral letter to Amit Kumar,
Physiotherapist, Suite 5, 379 Swanston Street,
Melbourne requesting home visits from the
physiotherapist. In your answer:
sentences
Use letter format
CASE NOTES 9.1

NOTES:
Today's Date
31/03/17
You are a school nurse at Toohey Hill Primary
School and recently there has been an
outbreak of threadworms at the school. In
response to this
situation write a general letter of advice to the
parents outlining common symptoms,
identification, occurrence, treatment and
medication and hygiene relating to
threadworms.
Signs and Symptoms
Intense itchy feeling around the anus
Restless sleep
Teeth grinding while asleep
Irritability
Loss of appetite
Occasionally slight stomach pains associated
with gastrointestinal upsets
Can cause urinary tract infections
NB. Many people with threadworms show no
symptoms
Identification
Resemble fine pieces of cotton thread up to
1.5cm long.
Appear on the outside surface of faeces
Active during the night
Occurrence
Common in warm weather – despite good
sanitation
Crowded living conditions promote the spread
of worms between family members
Children 5-14 most susceptible - adults can be
infected by eggs spread around in
home/school environment
Outbreaks noted at schools / day cares.
Treatment
Vermox or Combantrin-1 available from
pharmacists. Consult doctor or pharmacist
first
Not suitable for pregnant women or children
under two.
Only works on adult worms present in the
intestine when medicine taken.
Treat whole family at same time to minimize
risk of reinfestation
Recommend treat everyone again two weeks
after initial treatment if reinfestation
suspected
Hygiene
Morning shower or bath to remove eggs laid
during night
Ensure everyone always uses own towel and
facecloth.
During treatment change night
clothes/underwear of infected person daily.
Vacuum carpets often, especially bedrooms,
to remove dust.
Change bed-sheets frequently, especially first
7 to 10 days after start of treatment.
Keep nails of infected people short to reduce
chance of eggs being stored there.
Wash hands thoroughly after using bathroom
and before meals
Keep toilet and bathroom area clean.
WRITING TASK
Using the information provided, write a letter
addressed to “Parents of students at Toohey
Hill Primary School” providing information on
threadworm and its treatment.
In your answer:
sentences
Use letter format
CASE NOTES 9.2

MINUTES
NOTES:
You are a Registered Nurse at the Royal
Brisbane Hospital were Anthony Nutt is a
patient in your care.
Today’s date: 29/05/2017
Patient name: Anthony Nutt
Address: Unit 8, 37 Albert Street
Brisbane 4000
Age: 86 years
DOB: 19/07/1931
Next of Kin: Son, Joseph Nutt
Medical history
Breast Cancer 20 years ago- right total
mastectomy- did not receive adjuvant
radiation, chemotherapy, or hormone therapy
or medical follow-up post-operatively.
Dementia
Non-smoker
No known allergies
Non-drinker
Family History
Mother died of colon cancer
Social History
Retired 20 years ago
Married – wife suffering from newly onset
dementia
One son- Joseph Nutt, 52 years old, unmarried
– lives 30 minutes away
Diagnosis: recurrent infiltrating ductal
carcinoma of the breast.
23/05/2017
Presented to ER with ulcerated,
haemorrhaging right anterior chest mass
The patient- developed a mass on his anterior
chest wall -2 years ago
Mass increased in size, began to ulcerate –
bled this morning -- did not seek medical
treatment until this morning
Objective
Temperature - 97.4°F
Pulse- 80
RR - 14
Pulse oximetry of 100% on room air
BP - 162/88.
A right-sided pedunculated 8 cm × 7 cm mass
with a cauliflower-like appearance on chest-
ulcerated, erythematous, malodorous, and
with scant bleeding
White blood cell count 6,500
Haemoglobin 12.4
Haematocrit 36.2
Platelet count 178,000.
Creatinine of 1.72
Glucose 106
A CT chest - a soft tissue mass in right chest
wall measuring 5.2 × 2.75 × 5 cm with post-
operative changes of the right axilla.
Incisional biopsy of right breast mass
performed
28/052017
Pathology returned consistent with Recurrent
moderately differentiated duct carcinoma of
the breast with ulceration of overlying
epithelium.- Stage 3
Pt. not found to be suitable for chemotherapy
or curative treatment - Oncology evaluation
and geriatric evaluations by doctor
Pt. commenced on hormone therapy with
tamoxifen 20 mg daily with one course of
palliative radiation.
Family meeting called- son verbalized
concerns over mother’s state of health; son
unable to take time off work to care for
father-says he won’t be able to cope; hospice
care recommended for pt. –consensus
decision
Pt. to be transferred to Queensland Aged Care
Centre for hospice care
Bed available from 29/05/2017 for patient
Pt.’s wife to be admitted to the same facility
due to general deconditioning when bed is
available; mother to live with son interim
Discharge plan
Transfer to Aged Care home
Son will visit weekly
Contact community social worker to notify
son when bed available for wife at
Queensland Aged Care Centre
WRITING TASK
a referral letter to the Ms. Carrie Andrews,
Director of Nursing, Queensland Aged Care
Centre, 52 Albert Street, Brisbane 4101,
introducing the patient. Using relevant case
notes, give his background, medical history,
and treatment required.
In your answer:
sentences
Use letter format
CASE NOTES 10.1

NOTES:
You are a nurse with the Blue Skies Home
Nursing Centre. You visited this patient at
home today for the first time following a
referral from the Mater Public Hospital. He
was discharged from hospital on 17.3.08.
Name: Henry O’Keefe
Address: 12 Donaldson Street, Greenslopes
4121
Phone: (07) 3941 2267
Date of Birth: 2 February 1925
Admitted: 14.3.08
Diagnosis: Malignant Melanoma Left Shoulder
Medical History
Large lesion successfully removed 14.3.08.
Discharged 17.3.08
Needs assistance with showering and to dress
wound prior to removal of sutures at Mater
Public Hospital on 24.3.08
Family History
Married aged pensioner. Lives in housing
commission home with wife Dorothy also an
aged pensioner. No children
18.3.08. 1st Home visit
Showered patient. Wound dressed – healing
satisfactory no sign of infection Balance a little
shaky - complaining of increased arthritic
pains in hands and legs.
Currently taking Glucosamine & Chondroitin
Supplement recommended by GP. Pain
relieved with 2 Panadol 3 times daily.
Confused about why he had operation.
Dorothy concerned about future. Tells you she
will be 83 in August. Says Henry has not been
himself since the surgery. Keeps forgetting
things. She finds it difficult to manage the
house and garden. Neighbours are helping
with shopping. Kitchen and bathroom
disordered - trouble finding clean towels –
dishes piled in sink, bed unmade.
19.3.08
Henry showered and wound dressed. Still a
little unbalanced. Rests most of the day. Does
not remember being showered yesterday.
House still disorganised, washing piled up in
bathroom. Dorothy says she would be lost
without help from neighbours who also
appear to be cooking meals for the couple.
Concerns: Provided there are not
complications with the wound healing, your
role in providing nursing care ends when
sutures are removed on 24 March. You
consider that Jim and Dorothy need to be
assessed for further on-going assistance in
managing the house and garden and with
shopping and the preparation of cooking.
Plan: Request a home visit by the Aged Care
Assessment Team as soon as possible to fully
assess their needs and to arrange for
appropriate further assistance to be provided.
WRITING TASK
a letter to The Director, Aged Care Assessment
Team, Brisbane South Region, 78 Masterson
St. Acacia Ridge, Brisbane 4110. Explain why
you are writing and what types of assistance
may be required.
In your answer:
sentences
Use letter format
CASE NOTES 11.1

MINUTES
NOTES:
You are a Registered Nurse at Pullman
Medical Centre. Ms. Paula Anderson is a
patient in your care who is being transferred
to Holy Heart Hospital today for a colostomy
scheduled on 05/02/2018.
Patient name: Ms. Paula Anderson
DOB: 19/05/1954
Marital status: Married
Social background: Lives with husband -
very supportive
1 daughter-lives interstate Two sisters- live
nearby
Retired school teacher (English)
Hobbies: playing badminton, watching movies
Likes socialising, playing chess
Sedentary lifestyle – Overweight since 30’s
Medical background: appendectomy – 2003
# left leg – 2007 pneumonia – 2015
arthritis in hands – uses Voltaren
Diet: Red meat, processed meat
Fast food
Alcohol (Vodka, wine) – 4-5 days/wk.
Ex-smoker – quit 15 years ago
Nursing notes
28/12/2017 Visit to GP, 2- 3 bleeding from
rectum rectal exam- definitely palpable mass
Fast track referral for suspected colorectal
cancer
11/01/2018 8 cm mass on left lateral wall of
rectum likely to be carcinoma – referred for
colonoscopy
14/01/2018 colonoscopy- biopsies large
bowel mucosa taken
18/01/2018 CT & Local staging of primary
tumour with MRI
23/01/2018 Review of histology –
colonoscopy report
Diagnosis – Colon cancer
R/v by colorectal and general surgery
consultant CT – no evidence of metastatic
cancer
Recommended colostomy
Pt. advised of diagnosis and surgery
02/02/2018
Identified needs/problems:
Prepare for colostomy
Eating and drinking: Potential problems of
dehydration due to above
Anxious about probs of stoma on home and
social life. Involve family members in care
Objectives minimise risk of post-op.,
wound infection from bowel contents
Allow surgeons clear access to operation site
i.e. free from faeces
Complete pre-op. Care schedule
Encourage patient to voice concerns
Plan Rectal wash-out before bedtime for
three days
(daily)
Purgatives as desired
Low-residue light diet 02/02
Fluids only including soup and ice cream 02/03
Clear fluid 02/04
Charge Nurse to see the pt. to discuss
practical problems at home
Nil by mouth from 00.00 hours 02/05
Standard pre-op procedure
Ensure variety of acceptable drinks
WRITING TASK
write a letter to Ms. Meredith
Stevens, Charge Nurse, Holy Heart Hospital,
119 Red Sparrow Road, Docklands, Melbourne
outlining relevant findings and patient care
plan to prepare Ms. Anderson for the surgery.
In your answer:
sentences
CASE NOTES 12.1

NOTES:
You are the school nurse at a Toohey Point
Primary State School
Today’s Date 07/03/2010
Patient Details
Alison Cooper
Year 5 student
DOB: 14/6/2000
Height:138cm
Weight:40 kg Overweight for her age
Eczema outbreaks on hands and mild asthma
– has Ventolin inhaler No other significant
illnesses Youngest in her class
Social History
Father died in motor accident 18 months ago.
Lives with mother, a bank manager, working
full time
Middle child- brother, Simon, aged 7 and
sister,
Lisa, aged 12
Paternal grandmother lives near school -
provides after school and holiday care - looks
after children if unwell
School Medical Record
Regular absences from school dating back to
time
of father’s death Year 2: 3 days
Year 3: 4 days
Year 4: 10 days
Year 5: 8 days in first term
School Health Centre Records
2010
February 8: Complained of headache. Gave
paracetamol, rested and returned to class.
Noted eczema on hands red and weepy - has
ointment at home.
February 16: Complained of stomach ache.
Called grandmother for pick up.
February 22: Complained of aching legs. Called
grandmother for pick up.
March 4: Complained of headache. Gave
paracetamol, rested 1 hour, still had
headache.
Called grandmother for pickup.
March 6: Feeling nauseous - eczema on hands
red and weepy. Called grandmother for pick
up. 2009 February 15: Complained of
toothache. Called grandmother for pick up.
April 4: Complained of headache. Gave
paracetamol - rested 1 hour.
May 14: Headache, eczema on hands red and
weepy, rested 1 hour not better called
grandmother for pick up.
July 25: Feeling nauseous. Called grandmother
for
pick up. August 16: Slight fever. Called
grandmother for pick-up.
September 22: Feeling unwell. Eczema
irritating. Called grandmother for pick up.
October 23: Complained of stomach ache.
Rested 1 hour, returned to class.
November 27: Complained of headache. Gave
paracetamol, rested 30 minutes.
Social History
Alison started school well but since Grade 3
has had trouble concentrating – rarely
participates in class activities unless
encouraged. Avoids sporting activities –
standard of her school work is declining. Has
few friends and is often teased by her
classmates. Embarrassed about hands which
don’t seem to be responding well to ointment
suggested by chemist.
Mother was contacted by class teacher
regarding these issues. Says Alison is also
becoming withdrawn at home. Alison was
very close to her father – often talks to her
about him and cries because she misses him.
Seeks comfort in food like chips and cakes
after school.
Plan
Refer her to the school psychologist to find
out whether Alison has underlying grief
related or other psychological problems.
WRITING TASK
a letter to refer this girl to the school
psychologist, Barnaby Webster, to assess her.
Outline the purpose of the referral. Provide
details of significant factors which will assist
the psychologist to make this assessment.
In your answer:
sentences
Use letter format
CASE NOTES 12.2
CASE NOTES: 53-56

MINUTES
NOTES:
You are a Registered Nurse at Brockville
Hospital, Melbourne.
Patient name: Ms Elizabeth Carmel
Prefers to be addressed Izzie as:
Address: 456, Francis Street, Brockville,
Melbourne
Next of kin: George Thompson (husband)
BMI: 33
DOB: 02/04/1975
13/02/2017
Source of assessment: Husband
 Attended a party last night – complained
of abdominal pain and vomiting after the
party
 Today - became unconscious after feeling
unwell and increasingly drowsy at home
• BIBA with husband to hospital
• Unconscious on admission - Husband
thinks she fainted due to diabetes
• Diagnosed with diabetes 2 years ago –
poor management with diet and medication
(misses insulin doses)
• Diet: pancakes, 3-4 cups coffee,
cheese omelette, muffins, biscuits, Fish and
chips, fried chicken, sweetened juices, drinks
wine daily (1-2 glasses), whiskey occasionally
• Irregular eating pattern, fasting for
long periods of time/bingeing
• Underwent cataract surgery 10 years
ago
• Takes multivitamins at home daily
• Not very active – goes for a slow walk
1-2 times/week
• No hx of any allergies/no medications
• Nil relevant medical history
Objective
Breathing rate – 32/min
Cough – Nil
Colour – pale dry skin, lips pink
BP- 90/45 mmHG
P- 128/min Teeth- own
Mouth- clean and dry
Acetone breath
Blood gas analysis - severe metabolic acidosis
(pH- 6.74, bicarbonate 5 mmol/L, blood
ketones - > 8.0 mmol/L, serum glucose – 400
mg/dL, anion gap - 24)
Other lab tests – abnormal
Admission Dx- diabetic ketoacidosis
Nursing Management:
• Aggressive IV Fluids, norepinephrine,
bicarbonate, insulin, IV bolus
• No evidence of infection
• Regained consciousness
• K replacement administrated
• Intake/output accurately
• Oxygen sat.
14/02/2017
• Blood glucose, Fluid, electrolyte,

hydration status constantly monitored
• Mental status – normal
• Vital signs – normal
• Pt. urinating – renal function restored
• ECG reading – no sign of
hyperkalaemia
• K+ values approaching normal
• Pt. tired – reports feeling “crampy and
achey”
• Pt. educated re importance of taking
insulin on time, importance of timely balanced
meals to avoid emergency situations in future
15/02/2017
• Pt. ready to be discharged home with
husband
Discharge plan
• Initiate referrals to dietician,

outpatient diabetes education,
physiotherapist, District Nurse,
• Physiotherapist – initiate exercises for
weight-loss, increase physical activity
• Dietician – correct imbalanced
nutrition related to food, low-fat diabetic diet
schedule – pt. requests info on options when
out – send to home address
• Diabetes education from Diabetes
Specialist Nurse re diabetes (maintain
metabolic control in future, bingeing, wrong
foods & less physical activity hyperglycaemia,
monitor urine –ketones) – to risk of future
episodes – request home visit
• District nurse to monitor pt. -
compliance with diabetes management,
reinforce education re not missing insulin
dose and mealtimes, educate re timing of
insulin inj. & mealtime (30 minutes), monitor
compliance with diet regimen and weight-loss
program - Contact hospital immediately if
unable to retain oral fluids
• Review after 15 days
WRITING TASK
write a letter to Ms. Samantha Golden,
Diabetes Specialist Nurse, Victoria Health
Education Centre, Suite 548, 4th floor, 34
Collins Street, Melbourne requesting her to
visit your patient at home to provide
instructions on continued self-care after
discharge.
WRITING TASK
write a letter to Ms. Angelina Hobbs, Dietician,
Salona Health Clinic, Suite 404, 11th Floor,
Bourke Street, Melbourne.
WRITING TASK
write a referral letter to Ms. Pamela Wilkins,
District Nurse, requesting her to visit Ms.
Carmel at home for monitoring her condition.
WRITING TASK
write a referral letter to Ms. Alka,
Physiotherapist, GNB Medical Centre, 45-50
Sacramento Road, Coburg requesting her to
visit Ms. Carmel at home for initiating a
weight-loss program.
CASE NOTES 13.1

NOTES:
You are Grace Jones, a qualified nursing sister
working in Ward C25, Princess Alexandra
Hospital. Contact Ph. 07 3897 7642.
Annette Mac Namara is a patient in your care.
Name: Annette Mac Namara
Address: Unit 15, 86 Smart St, West End
Phone: (07) 3379 5926
Date of Birth: 14 June 1936
Social Background
Single Age Pensioner - Recently moved to a
small flat in new suburb. House she rented for
10 years was sold. Feels increasingly lonely
and isolated - rarely sees neighbours –
transport problems make it impossible to
continue to attend bowls and bridge clubs.
Next to kin, Niece – Stella Attois Ph 075 5984
7216 lives and works in Southport - generally
visits once a fortnight.
Medical History
Date of admission: 20-05-2009
Date of Discharge 22-05-2009 – provided no
complications and home assistance arranged.
Admitted to hospital following fall. Slipped
and fell while descending stairs to put out
garbage. Xray revealed fractured right wrist –
Laceration to left hand caused by broken
glass. Stitches required- Severe bruising of
right shoulder and lower back.
Medications
Karvea 150mg daily am – history of high blood
pressure now controlled Normison 10mg-1
nightly for insomnia when required. Pain relief
– 2 Panadol 4 hourly while pain persists.
Discharge plan
Organise daily visits from Blue Nursing Service
to assist with showering and to dress hand
wound. Social Worker to organise Meals on
Wheels and physiotherapy. (niece will visit at
weekend to help with housework and
shopping) Stitches to be removed and
situation to be reviewed at Out
Patient Department appointment - 10.30 am
3105-09
WRITING TASK
a letter to the Director, Blue Nursing Service,
207 Sydney Street, West End.
In your answer:
sentences
CASE NOTES 13.2

MINUTES
NOTES:
Name of the Patient: Vanessa Stanley Age: 85
years old.
Telephone number: +61 34974 5659
Social History: Lives alone No Children
Her neighbor, mariya, visit her house often
Sister lives in London with her family, two
children. Brother lives in Texas, High School
teacher and divorced.
Hx: Bilateral lower extremity edema, cellulitis
of lower extremities, Renal insufficiency
Hypercholesterolemia and obesity,
Incontinence of bladder & bowel at times HTN
Venous stasis
Ambulates and transfers independently with
walker
Recommended: Due to her weakness and
limited physical abilities, personal care is
recommended.
Discharged Date: Discharged from the hospital
on the 20th of
April, 2018 Patient requested for home care
services.
WRITING TASK
a letter to Grace
Gerome “Your Choice Home Care Agency”,
Leichhardt NSW,
Australia, making a request for the agency to
provide health care services to the patient.
In your answer:
sentences
CASE NOTES 14.1

NOTES:
Patient Details
Jim Middleton aged 84 was admitted to your
ward following surgery for a left inguinal
hernia. His doctor has advised he can be
discharged within 48hrs if there are no
complications following the surgery. Jim
reports some pain on movement but has
recovered well from the surgery and is keen to
return home.
Name: Jim Middleton
Date of Birth: 3 July 1924
Admitted: 7 July 2008
Planned Discharge Date: 9 July 2008
Diagnosis: Left inguinal hernia
Medical History
Hypertension diagnosed 1998
Medication Atacand 4mg daily
Family History
Married 50 years to wife Olga DOB 8.2.32 –
one son living in USA Jim is Second World War
veteran – served two years in Borneo –Prison
of War 16 months. Own their own home with
large garden which they maintain without
assistance. Very independent and proud that
they have never applied for a pension or
home assistance. Have always managed quite
well on their income from a number of
investments.
Olga told you she is worried as income from
these investments has recently been
significantly reduced due to severe stock
market falls. She is concerned Jim will not be
able to continue to maintain their garden and
they will not be able to afford a gardener or
any other help at this time.
Transport is also a problem as Olga does not
drive. Not close to any reliable public
transport so will have to rely on taxis. Olga
thinks they may now be eligible to receive a
pension and other assistance from the
Department of Veteran Affairs but doesn’t
know how to find out - doesn’t want to worry
Jim.
Olga is in good general health but becoming
increasingly deaf - finds phone conversations
difficult. She would appreciate a home visit.
You agree to enquire on her behalf. Their
address is
22 Alexander Street, Belmont, Brisbane 4153
Phone (O7) 6946 5173
Discharge Plan
Must avoid any heavy lifting
Should not drive for at least six weeks
Light exercise only
May take 2 Panadol six hourly for pain
Appointment made to see surgeon for post
operation check at 10am on 11 August
Contact Department of Veterans Affairs re
eligibility for pension and home help
WRITING TASK
a letter to The Director, Department of
Veterans Affairs, GPO Box 777 Brisbane 4001.
In your letter, explain why you are writing and
the assistance they are seeking.
In your answer:
sentences
CASE NOTES 14.2
CASE NOTES: 25
MINUTES
NOTES:
Hospital: Prince of Wales Hospital
Patient Details
Name of the Patient: Harley Simon
Age: 55
Height: 5’7”
Weight: 150 lbs.
Social History: Lives with his wife and
daughter Speaks only French (daughter acts as
an interpreter)
Address for correspondence: 201/275 Alfred
St, North
Sydney, NSW
Patient Medical History
Hx: Early dementia (as per his MD, it is
progressing fast) (2010).
BP (2008)
Sugar (2008)
Obesity
HTN
DJD and depression
Allergic to Peanuts
Ambulates with a cane and contact guard
Active at night and wants to sleep during the
day
Admitted: Admitted on 22nd January, 2018

due to complaints of high fever and body pain,
headaches,discomfort, poor appetite.
BP noted was 180/110 mm Hg
Sugar: Normal
Prescription: Paracetamol (500 mg) / 3 times
in a day Aspirin 500 mg (recommended if
there is more pain)
WRITING TASK
a letter to Dr. Peter Daniel, 435 Fitzgerald St,
North Sydney, Australia, who will be taking
care of the patient after discharge from the
hospital where you are working.
In your answer:
sentences
CASE NOTES 15.1

NOTES:
You are Sonya Matthews, a registered nurse
at the Spirit Hospital. Robyn Harwood is a
patient in your care. Read the case notes
below and complete the writing task which
follows.
Patient Details
Name: Robyn Harwood
Address: 8 Peach St, New
Farm Phone: (07) 3397 2695
Date of Birth: 4 February 1950
Social Background
Marital status: Widow. No children. Lives
alone
Next of kin: Megan Mack (Niece)
Niece lives with husband in Sydney who works
as software engineer for Google Australia.
Sister died recently. No other relatives.
Medical History
Diabetes Mellitus Type 2
Metformin 500mg mane
Diagnosis
Right partial rotator cuff tear Presented to
Spirit hospital with pain and weakness in the
right shoulder, especially when lifting arm
overhead.
Descending stairs at home and slipped, falling
onto outstretched arm. X-ray and MRI showed
a partial rotator cuff tear.
Orthopaedic surgeon discussed surgery.
Patient prefers to try non-surgical treatment.
Date of admission: 30-06-2011
Date of discharge: 12-07-2011
Treatment
Ibuprofen orally QID
Cortisone injections
Daily physiotherapy
Nursing Care Needs

Needs blood glucose level monitoring 4 hourly
May be elevated because of cortisone
Needs assistance with shower and housework
Orthopaedic review on 01/08/11.
WRITING TASK
a letter to the Nursing Director Ms. Jenny
Attard of the Community Home Care Agency,
requesting visits from the home care nurse.
In your answer:
sentences
Use letter format
CASE NOTES 15.2

MINUTES
NOTES:
Hospital: Bloombay Hospital
Patient Details
Name of the Patient: Agnes Moore
Age: 53 Height: 5’2” Weight: 147 lbs.
Telephone number: +61 2 9126 9264
Social History: Husband is retired
One daughter (married and settled in London)
Address for correspondence: 1/11-13 Albany
St, St Leonards NSW, Australia.
Patient Medical History
Dx: Hypertension and diabetes (diagnosed on
June 12, 1996) Peripheral Artery Disease of
the Legs (November, 2006) Left foot turns out
on ambulation (her husband stated that she
has a weak ankle and chronic burning pain in
it) Admitted: Admitted on 2nd February, 2018
due to problems with breathing,BP was noted
as 170/110 mm Hg Lisinopril was given
Condition was noted as stable (needs regular
check- ups)
Tests conducted: urine test & blood test
(normal)
Medical Course: Recommended the same
prescription that the patient was using for
Hypertension / Diabetes
WRITING TASK
a letter to
Dr. Alexander Samuel, 36 Pacific Hwy, St
Leonards NSW, Australia, explaining the
condition of the patient in detail and
highlighting the medication and care which is
required.
In your answer:
sentences
CASE NOTES 16.1

NOTES:
You are a nurse at North Romand Infant
Welfare Centre.
You visited this patient at home today for the
first time, after a referral from the maternity
hospital.
Name: Guy Hoang Chueng
Date of Birth: 17.05.53
Gender: Female
Occupation: Home duties
Personal History
Recently migrated (1/1991) with husband and
3 children (survivors of 6 pregnancies) from
Vietnam to Australia
Family Background
Husband works in factory: setting up small
Import business:
English at night school.
Children (boy 13, boy 11, girl 7) all at school;
working hard to adjust. Strong family
commitment to
school/work/study/business/Increasing
financial stability/learning English: may not
provide necessary assistance to overcome
operation and manage new baby.
No other family in Australia.
Medical History
No operations/illnesses
6 normal pregnancies previously, birth weight
approx. 2.8 kg.
10/7/1992
Incoordinate contractions and inadequate
outlet-
Caesarean section
Birthweight 4 kg (probably result of recently
improved diet/antenatal care).
? Circumstances not understood by patient;
language barrier / poss. Cultural differences.
20/7/1992
Mother sutures removed: suture lines healed.
Baby: no jaundice; breast feeding satisfactory,
normal weight gain.
Mother and child discharged from hospital.
27/7/1992
1st home visit
Most time since operation depressed and in
bed
(reasons unclear, but suspect due to
circumstances of operation).
Physically well. Apparent resistance to medical
intervention in hospital (language barrier).
Requirements
? Understanding of reasons for Caesarean
section.
? Home help.
Plan
Refer to social worker; arrange management
plan.
WRITING TASK
a letter of referral to Hoa Tran,
who is a Cambodian social worker with
Romans
Council
Introduce Mrs Chueng and explain why you
are referring her to the social worker. Discuss
reasons for her depression and explain how
you think Mrs Tran can help.
In your answer:
sentences
CASE NOTES 16.2

MINUTES
NOTES:
Hospital: Royal Perth Hospital
Patient Details
Name of the Patient: John Williams
Age: 68
Height: 180cm Weight:80kg.
Social History: Lives with his daughter
Daughter provides 24-hour supervision and is
the primary caregiver. SmokesDoesn’t drink
Address for correspondence: 172 Auckland
Street Gladstone, Australia.
General Conditions
Sensory vision WNL with glasses Somewhat
hard of hearing
Speech is clear with mild dysphasia
Ambulates with a cane or rolling walker
independently
Sometimes needs supervision or contact
guard on the stairs
Transfers independently
Continent of bowel, incontinent of bladder
Wears disposable undergarments
Medical History:
24th october, 2016: Diagnosed to have high
BP; 20th November, 2017: mild chest pain.
Admitted on: 10 April, 2018 Presenting
symptoms:
Pain, aches, discomfort and tightness across
the front of the chest BP noted as 170/110
mm Hg
Myocardial perfusion scintigraphy confirmed
the diagnosis of angina operation performed
on 18th of April 2018.
WRITING TASK
a letter to Dr. Kendrick Johnson, St.Vincent’s
Hospital, Australia who wanted you to provide
all the details about the patient’s medical
history before taking the patient into his care.
In your answer:
sentences
CASE NOTES 17.1

MINUTES | WRITING TIME: 40 MINUTES
NOTES:
Health Facility: Glenelg Aged Care Home,
Anzac Highway, Glenelg
Patient Details: Alex Maydew, 23, has
neurological injuries as a result of a car
accident 10 months ago.
Past Medical History: NAD
Social History:
Alex was a third year Physical education
student at the University of South
Australia before the accident
Keen mountain climber and surfer
Mother and sister very attentive and caring
Mother is a nurse at Modbury Hospital
Nursing Notes:
4 months in coma at Royal Adelaide
Hospital
4 months in coma at Glenelg Aged Care
Home
Woken from coma 2 months ago with normal
brain function but loss of speech facility
Confined to wheelchair. Improving mobility
with physiotherapy
Depressed to be in an aged care setting
Mother believes that the aged care setting is
slowing his recovery
Able to use a computer - could possibly
resume part-time study
WRITING TASK
Write to the Director of the Julia Farr
Rehabilitation Centre, 229 Fullarton Road,
5097, requesting a transfer of your patient to
more appropriate care. Mention need for
ongoing speech therapy and physiotherapy,
and possible continuation of online studies In
your answer:
sentences
CASE NOTES 17.2

MINUTES
NOTES:
You are Susan Hosbel, a senior nurse, working
with
Santacruz Health Care Agency. Hannah Morris
is a patient. Read the case notes below and
complete the writing task which follows.
Name: Hannah Morris Date of
Birth: 14 May, 1973.
Address for correspondence: 1/11-13 Albany
St, St Leonards NSW, Australia. Contact
number: +61 34527 2382 Social Background:
Lives with her husband who is a retired army
officer Three children (two daughters and one
son) –Two daughters live in London & son in
New York.
Past medical history: Diabetes Mellitus and
Hypertension.
Chief Complaints: Headache and giddiness.
Headache began 2 weeks ago (it has occurred
episodically since then) Pounding in quality,
localized to both frontal areas. Giddiness
occurred while doing household chores 3 to 5
times over the last 2 weeks.
Not associated with nausea, vomiting, or light-
sensitivity Relieved by over-the-counter
analgesics No changes in her vision
No previous history of similar headaches No
family history of intractable headaches
Suffered two episodes of impaired
consciousness (over the last 2 weeks), one
while cooking (approximately 10 days ago)
and the other while driving (just two days ago)
.No jerking of
the limbs or incontinence was observed
Physical examination:
Vital Signs T: 97.2 P: 78 R: 21 BP: 160/80
General physical exam: Normal. Neck: supple.
Neurological exam:
Visual acuity: OS 20/25; OD 20/30
Motor: Normal muscle tone and strength, all
muscles tested Funduscopy: Bilateral
papilledema, R retinal hemorrhage MMSE:
28/30.
CN: PERRL, EOMI, Visual fields full to
confrontation.
Sensory: Normal.
Babinski’s sign: Negative. Coordination:
Normal.
DTRs: Brisk and symmetrical throughout.
Station and gait: Normal.
Laboratory studies:
Toxicology screen, electrolytes, and ECG were
normal.
Head CT: Normal.
Head MRI: No ventricular enlargement. EEG:
Normal
Course of illness:
Tramadol (Ultram®) for pain, Amlodipine
(Norvasc®) (for high BP) &Metformin(for DM).
A lumbar puncture was done: opening
pressure was greater than 450 mm of water.
Cell counts were WBC 213 RBC 46.
Differential: segs 1 bands 0 lymphs 81 monos
18.
Protein75. Glucose 24
CSF cryptococcal antigen was positive.
WRITING TASK
a letter to the senior doctor, Luke Davies at
Royal Perth Hospital, 56 Churchill Ave, Subiaco
WA, Australia, stating all the details about the
patient and requesting for him to look into the
case.
In your answer:
sentences
CASE NOTES 18.1

NOTES:
Hospital: North West Hospital Rehabilitation
Unit
Patient Details: Name Mr Ted Watson
Age: 72 y.
Marital status: widowed -10 yrs
Next of kin: daughter Margaret Alwood ph.
9825
3899
Admission Date: 10 May 2007
Discharge Date: 12 August 2007
Diagnosis: ↓ed mobility - surgical repair
(dynamic hip screw) of # R Neck of Femur (1
May
2007 at Newtown Hospital
Past Medical History:
NB: Medical Alert
Anaphylactic reaction to amoxicillin/penicillin
(antibiotics) 1997
Social History/Supports:
Retired storeman - Ramsay's Ltd
Lives alone- ground floor flat in public housing
Hobbies: quiet reading / listening to 'big band
music/TV sports
All home aids installed by O.T
Very supportive daughter, visits frequently ?
anxious how father will manage when returns
home
Local day centre 2 x wkly
Local council home support visits
Medical Progress Slow due to
Febrile episode - periods of confusion. Caused
by urinary tract infection.
Treated w. trimethoprim (antibiotic), Ural
(urinary alkalizer) and paracetamol
(analgesic)
Now fully resolved.
Onset of large arterial leg ulcer R ankle.
Regular dressings, now ↓ing in size.
Nursing Management:
Vital observations stable, afebrile.
Mobility- V. slow independent ambulation
with pick-up frame
Hygiene: max. assistance with
showering/dressing
Continence: self care with permanent
indwelling catheter.
Skin integrity: DuoDerm (occlusive) dressing
wkly to ulcer.
Psychosocial: alert, reserved.
Discharge Plan:
Continue with all home supports
Community nurse referral-
for hygiene: assistance with
showering/dressing
wound management
urinary catheter change 6-wky
ongoing monitoring and care
WRITING TASK
You are the charge nurse on the hospital ward
where Mr Ted Watson has resided during his
hospital stay. Using the information given in
the case notes, write a letter of referral to the
Community Nurse Supervisor at the
Community Nursing Centre, Newtown, who
will be attending to Mr Watson following his
discharge.
In your answer:
sentences
CASE NOTES 18.2

MINUTES
NOTES:
Ms Nicola Boyle is a 20 year old woman who
has just given birth to her first child at the
St.Michael’s Hospital in South Wales. You are
the nurse looking after her.
Patient Details
Address: Flat 8, Collins Street, West End 4101
Phone: (07) 32354075
Date of Birth: 8 August 1998
Admitted: 10th January 2018
Discharged: 15th September 2012
Marital Status: Single Country of birth:
London
Social Background
Nicole is single and has had no contact with
father of child for 4 months. She does not
know his current address.
She arrived in Australia as a part of her job in
2015 .No family members in Australia. Parents
and sister live in London. Does not currently
have contact with them.
Lives in a rental share flat with one other
woman. Currently receives sole parent
benefits.
Feels very isolated and insecure. Doubts her
ability to be a good mother and has talked
about offering the baby for adoption.
Medical History
General health good
Had appendicectomy at 10 years, non-smoker
No alcohol or illicit drug use. No drug or other
allergies
Obstetric History
First pregnancy
Attended for first antenatal visit at 14 weeks
gestation.
8 antenatal visits in total.
No antenatal complications.
Birth details
Presented to hospital at 1600hrs on 10th
January
Contracting 1:10mins
1st stage of labour: 16 hrs
Mode of delivery: Emergency Caesarean
Section Reason: Fetal distress and failure to
progress.
Baby Details
DOB: 11th January 2018
Time: 1120hrs
Sex: Male Weight: 4.3kg
Apgar Score: 6 at 1 min, 9 at 5 mins
Resusitation: O2 only for few minutes
Postnatal Progress
Maternal post partum haemorrhage of 800mls
Blood loss now minimal
Wound: Clean and dry Haemoglobin on
12/01/18: 90 g/L Started on Fefol (Iron
supplement) and Vitamin C Started breast
feeding but not confident.
Prefers to change to bottle feeding.
Not confident in bathing and caring for baby
Baby weight at discharge: 4.0 kg
Feeding well
No jaundice
WRITING TASK
a letter to The Director,
Community Child Health Service, 41 Vulture
Street, West End, Brisbane 4101 requesting a
home visit to provide advice and assistance
for Nicole and her baby.
In your answer:
sentences
CASE NOTES 19.1

NOTES:
Ms Jane Simms is a 46-year-old patient on the
ward of a rehabilitation hospital in which you
are Charge Nurse
Patient Details
Marital Status: Single
Admission Date: 26 July 2008 (South Eastern
Rehabilitation Hospital)
Discharge Date: 16 August 2008
Diagnosis: Progressive Multiple Sclerosis
Social Background:
Lives with unmarried sister in 3-bedroomed
house
Employed as graphic artist until September
2007 Now invalid pensioner.
Medical Background:
Multiple sclerosis diagnosed 20 yrs ago/recent
exacerbation Obesity
↑depression since stopping work Pressure
area-R buttock
Nursing Management and Progress:
Medications previous regime of ACTH and
corticosteroids and recently prescribed
Prothiaden 150mg daily
antidepressant: dosulepin hydrochloride
Daily dressings → R buttock. Now healed
Low calorie diet
Range of motion, stretching and strengthening
exercises
Occupational therapy
Assessment: Good progress all areas
Discharge Plan
Monitor medications (NB Prothiaden)
Preserve skin integrity
Monitor weight
Continue exercise program
Encourage new activities/interests
WRITING TASK
write a letter to Ms Mary Wright, the
Community Nurse at Lakeside Community
Health Centre, 50 Hope Street, Newtown, who
cared for Ms Simms at home until her recent
admission to hospital. The letter is to
accompany Ms Simms home upon her
discharge tomorrow.
In your answer:
sentences
CASE NOTES 19.2

MINUTES
Patient Details
Name: Ms. Saniya Hofstader
DOB: 14/03/1954
Address: New resident of Dementia Specific
Unit, Westside Aged Care Facility
Marital status: Single
Under the Australian Guardianship and
Administration Council protection
Medical History
Coronary artery disease (CAD) since 2001,
takes Nitroglycerine patch, daily
Stroke May 2005, after stroke - unsteady
gait& slurred speech In 2014 - diagnosed with
severe dementia - able to understand simple
instructions only, confused and disorientated.
Diabetes mellitus (type 2) since 2006– on a
diabetic diet Osteoarthritis of both knees 22
yrs.
Voltaren Gel to both knees BD
Weight gain 12 kg over the last 6 months,
current weight 106kg
(BMI of 30)
Chronic constipation, takes Laxatives PRN
No allergies to medication or food
No teeth – has entire upper
or lower dentures, sometime refuses to wear
dentures due to confusion and disorientation
Increased appetite– usually eats full portion of
offered meals x 3 times daily and, also, goes
into other residents’ rooms and eats their
food as bananas, biscuits or lollies
Social History
No friends
Lack of interests, but likes colouring and
watching sports in TV
↑emotional dependence on nursing staff
Non-smoker, no use of alcohol or illegal drugs
15/02/12
Chest infection. Keflex 500mg QID x 7 days
26/02/12
Occasional cough & episodes of SOB with
↑RR 27/02/12
Sporadic throat clearing after eating yoghurt
20/03/12
1700 hrs
Episode of choking on a piece of food (? food
not chewed properly). She suddenly turned
blue, grabbed the throat with both hands and
coughed. The piece of solid food was
removed.
1710 hrs
Nursing assessment after treatment Pulse 100
BPM
 BP 130/80 mmHg
 TRR – 37.2– 21/min ° C
 BSL – 6.0 mmol/L
 1800 hrs
 No complaints
 Pulse – 80 BPM
 BP – 120/70 mmHg
 RR – 18/min
 T- 37.0 °C
 Skin: normal colour.
Hospital visit not required
WRITING TASK
You are a Registered Nurse at the Dementia
Specific Unit. Using the information in the
case notes, write a letter to Dietician, at
Department of Nutrition and Dietetics, Holy
ghost’s Hospital, Sydney. In your letter explain
relevant social and medical histories and
request the dietician to visit and assess Ms.
Hofstader’s swallowing function and
nutritional status urgently due to a high risk of
aspiration.
In your answer:
sentences
CASE NOTES 20.1

NOTES:
Patient History
Baby: Maria Ortiz, 7 days’ old
Maria Ortiz is a seven-day old baby at Nativity
Hospital. Today her mother has been
transferred to another hospital nearby (O’Lore
Emergency, Westfield). Both are being
discharged by this evening.
Social History
 Mother Voletta Ortiz, DOB: 07/08/1967
 Father Jose, 36 years, Security guard
(night shift)
 Other children - Sam, 5 years (currently
not attending school) Teresa, 3 years.
 Accommodation Two-bedroom flat
(rented).
 No car: 20-minute walk to shops
 Father unable to assist with children
(night work)
Nursing Notes
Baby
 Normal birth
 Baby's weight - birth-3010 gm: Discharge -
3020 gm.
 Reluctant to breast-fed and bottle-feed
 Baby sleepy during day, crying at night.
Mother
 Ortiz very tired, postpartum bleeding,
three times but ended 4 days ago.
 Oxytocin administered.
 Anxious about coping with 3 children after
discharge.
WRITING TASK
a letter of referral to the maternal and child
health nurse who will provide follow-up care
for both baby and mother.
Recipient: Ms Josie Hext, Maternal and Child
Health Centre, 133 Elm Grove, Westfield, 2692
In your answer:
sentences
CASE NOTES 20.2

TIME ALLOWED: READING TIME: 5 MINUTES
NOTES:
You are Janice Rose a registered nurse in the
Coronary Care Unit, St. Johns Hospital,
London. Jamie Morgan is a patient in your
care.
Patient Details
Name: Jamie Morgan DOB 22 February 1956
Address 9476 Old Dam Road, Goondiwindi
QLD 4390
Next of Kin Brother, Justin morgan 72 Burke
St, Cunnamulla QLD 4490
Admitted: 27 September 2017
Diagnosis: Obstructive coronary artery disease
Operation: Coronary artery bypass grafts (x 4)
on 29 September 2017
Social History
Never married
Lives alone in own home just outside
Goondiwindi Fencing contractor
Medical History
 Smokes 30 cigarettes/day
 Alcohol: 3 x 300ml bottles beer / day
 Ht 177cm Wt 96kg
 Usual diet: sausages, deep fried chips,
burgers,eggs,
 MacDonalds
 Allergic reaction to peanuts
 Routine postoperative recovery
 Advised to cease smoking, reduce alcohol
Low fat diet
 Walking well
 Wounds healing well
 Routine visit from Social Worker
Discharge Plan
Returning Home to Goondiwindi
Appointment made for follow up visit to local
GP Dr. stevensen George
2pm 10/10/17
rehabilitation exercise program
WRITING TASK
Mr. Morgan has requested advice on low fat
dietary guidelines and healthy simple recipes.
Write a letter to the Community Information
Section of the Heart Foundation, Gosbey
Simon, Brisbane on the patient’s behalf. Use
the relevant case notes to explain Mr.
Morgan’s situation and the information he
needs.
Include Medical History, Body Mass Index and
lifestyle. Information should be sent to his
home address.
In your answer:
sentences
CASE NOTES 21.1

NOTES:
writing task which follows:
Today’s Date: 21/03/12
Patient Details
Name: Ms. Nina Sharman
DOB: 09/02/1951
New resident of Dementia Specific Unit,
Westside Aged Care Facility Single
Under the Australian Guardianship and
Administration Council protection
Medical History
Ischemic heart disease (IHD) since 2005, takes
Nitroglycerine patch, daily
Stroke May 2011, after stroke - unsteady gait
In 2011 - diagnosed with severe dementia -
able to understand simple instructions only,
confused and disorientated
Diabetes mellitus (type 2) since 2000 – on a
diabetic diet
Osteoarthritis of both knees 20 yrs.
Voltaren Gel to both knees BD
Weight gain 10 kg over the last 5 months,
current weight 106kg (BMI of 30)
Chronic constipation, takes Laxatives PRN
No allergies to medication or food
No teeth – has entire upper or lower
dentures, sometimes refuses to wear
dentures due to confusion and disorientation
Increased appetite– usually eats full portion of
offered meals x 3 times daily and, also, goes
into other residents’ rooms and eats their
food as bananas, biscuits or lollies
Social History
No friends
Lack of interests, but likes colouring and
watching TV
↑emotional dependence on nursing staff
Non-smoker, no use of alcohol or illegal drugs
15/02/12
Chest infection. Keflex 500mg QID x 7 days
26/02/12
Occasional cough & episodes of SOB with
↑RR
27/02/12
Sporadic throat clearing after eating yoghurt
20/03/12
1700 hrs
Episode of choking on a piece of food (? food
not chewed properly). She suddenly turned
blue, grabbed the throat with both hands and
coughed. The piece of solid food was
removed.
1710 hrs
Nursing assessment after treatment o Pulse
110 BPM o BP 120/70 mmHg o RR – 22/min o
T– 37.1° C o BSL – 6.0 mmol/L
1800 hrs
No complaints
o Pulse – 88 BPM o BP – 115/70 mmHg o RR –
16/min o T- 37.0 °C o Skin: normal colour. o
Hospital visit not required
WRITING TASK
You are a Registered Nurse at the Dementia
Specific Unit. Using the information in the
case notes, write a letter to Dietician, at
Department of Nutrition and Dietetics, Spirit
Hospital, Prayertown, NSW 2175. In your
letter explain relevant social and medical
histories and request the dietician to visit and
assess Ms. Sharman’s swallowing function and
nutritional status urgently due to a high risk of
aspiration.
In your answer:
sentences
CASE NOTES 21.2

MINUTES
NOTES:
Zane Khalifa was admitted through the
Children’s Emergency Department for acute
meningitis as a result of a complication
following chickenpox.
Patient History
 Address: 28 Seaview Street Cleveland QLD
Phone:
 (07) 35443574
 Date of Birth: 13 March 2013
 Admitted: 28th October 2017
 Gender: Male
 Discharged: 8th november 2017
 City of birth: Johannesburg
 Diagnosis: acute meningitis
Social History
Parents: Zoya & Abayomi Khalifa, refugees,
arrived in Australi in 2015. Employment:
Abayomi: helsey strawberry factory, planter
Zoya: housewife
 Accommodation: Recently moved to
rental accommodation
 GP: No family doctor
 Sibling: 3 year old sister, Siri Language:
Zulu,Arabic
 Interpreter needs: Abayomi understands
spoken English but has limited written
skills. Zoya has limited understanding of
English.
 Abayomi attends English classes.
Medical History
Parents state that both children had some
kind of vaccination at birth but the vaccination
record has been lost. Parents unaware of
vaccine for chickenpox.
Discharge Plan
Appears to have fully recovered from
chickenpox and acute meningitis. Will need
advice on recommended vaccines for both
children. Will need neurological check-up.
WRITING TASK
Health Service, 501 Stanley street, Cleveland,
requesting follow-up of this family.
In your answer:
sentences
CASE NOTES 22.1

NOTES:
You are a district nurse (nurse caring patient
at their home) taking care of Mrs Anna Paro,
who needs daily dressing for the leg ulcer.
Name: Anna Paro Age: 75 years
Medical history:
 COPD
 Osteoarthritis
 Appendectomy - 2009
 Suffering with leg ulcer
 Taking salbutamol pm
 Ipratropium 25/250 2 puffs daily
Social history
 Lives alone, husband died
 Two children one native, other overseas
10.03.2018
Subjective:
 SOB increase (especially day activities, not
at night
 Salbutamol ineffective
 Need rest or sit down to hold breath back
Objective
 Comfortable at rest, no sob
 RR 18bts/m. BP 130/80mmHg
 Auscultation. Good air entry both sides,
little wheeze on left side
 Observed patient’s inhaler use –
inappropriate
Diagnosis:
 S0B worse due to COPD, inhaler use
Treatment:
 Ventolin 2 puffs under supervision
 Educated about inhaler use with spacer
patient claims “this is not the way my
pharmacist told”
Plan
Refer/ advice pharmacist inhaler
WRITING TASK
Write a referral letter to Anna paro
pharmacist to teach her about inhaler In your
answer:
sentences
CASE NOTES 22.2

MINUTES
NOTES:
Lisa Macgrath is a resident at the Beverly Hills
Retirement Village. She needs urgent
admission to hospital. You are the night nurse
looking after her.
Patient Details
Address: Beverly Hills Retirement Village, 83
Waterford Rd,
Annerley, 4101
Phone: (07) 3451 5794
Date of Birth: 20/11/1925
Marital Status: Widowed
Country of birth: Australia
Social History
Moved to a retirement village following the
death of husband in January 2008.
Next of kin: Son, Alex Macgrath, 33 Palmer
Street, Warwick 4370 Ph (07) 4693 6345.
Retired triple certificate nurse - was the
matron of a small country hospital for 16
years. Very aware of and interest in health
issues. Likes to discuss and be kept fully
informed of any changes to her medication or
treatment.
Normally alert and orientated. Enjoys Ludo,
caroms, bingo and reading.
Medical History
Hyperthyroidism since 2002
Diabetes mellitus since 2004
Hypertension since 2006
Cataract since 2005, Allergic to penicillin drugs
and seafoods.
Prescription Medications
Karvea 150mg 1 daily Oroxine 0.1mg 1 daily
am Glumetza 500mg 1 daily
Can-C Eye Drops 4drops each eye, Normison
10 mg as required
Non prescription Medication
Health care Glucosamine hcl 1500mg Tablet -
1 with breakfast for arthritis Vitamin C
Complex Sustained Release – 1 with breakfast
Mobility / Aids
Independent with walking stick. Arthritis in
hands. Wears glasses
Continence: Requires continence pad
Recent Nursing Notes 16/12/17 Flu
vaccination 17/12/17
Complaining of indigestion following evening
meal. Settled with Mylanta
18/12/17
Unable to sleep – aches in shoulder. Settled
following 2 Panadol and 1 Normison
19/12/17
Requested Mylanta for indigestion,Panadol for
shoulder pain – slept poorly
20/12/17 am
Tired and feeling generally weak. BP 180/95.
Confined to bed. GP called and will visit
11/7/12 after surgery.
20/12/17 pm
Didn’t eat evening meal. Says felt slightly
nauseous. Trouble sleeping, complaining of
shoulder and neck pain. BP 175/95 Given 1
Normison
2 Panadol at 10pm
Rechecked 10pm – Distressed, pale and
sweaty, complaining of persistent chest pain,
BP 190/100. Ambulance called and patient
transferred.
WRITING TASK
Write a letter for the admitting doctor of the
Spirit Hospital
Emergency Department. Give the recent
history of events and also the patient’s past
medical history and condition.
In your answer:
sentences
CASE NOTES 23.1

NOTES:
Hospital: Intensive Care Unit, Flinders Medical
Centre
Patient Details
 Name: Diane Carpenter
 Age: 58
 Marital Status: Divorced
 Next of kin: 2 married daughters (both live
locally)
 Admission Date: 10 May 2009
 Discharge Date: 24 May 2009
Diagnosis:
 (L) Lung resection
Past Medical History:
 Breast cancer 1988
 Full mastectomy September 1988
 Good response to tamoxifen and
remission until 2009
 Dyspnea April 2009 - investigations
revealed small patches in left lung
 Has had Generalized Anxiety Disorder
since 20's - sometimes on medication for
this but not at present
Social History:
 Recently migrated from Canada (2001)
 Supported financially by children
 Court secretary but unable to work due to
visa issues
 Lives in small rented unit
 Drives own car
 Small circle of good friends
Medical Progress:
 Pneumonia - day 4
 Treated with antibiotic therapy and
ventilation
 Now fully resolved
Nursing Management:
 Fluid management
 Oxygen therapy
 Nutritional support
 Physiotherapy initiated
 Mobility: Very slow-patient is reluctant to
walk
 Psycho/social: difficulties coping
Discharge Plan
 On-going physiotherapy
 Needs encouragement to mobilize
 Initiate psychiatrist visits (coping
strategies)
 Organize visits between psychiatrist and
daughters - encourage them to be more
supportive emotionally
 Chemotherapy appointments at Flinders
Medical Centre to begin 6/6/09
 Monitor medications (antibiotics,
tamoxifen)
WRITING TASK
write a letter to the Director of the
Repatriation General Hospital, 216 Daws
Road, Daw Park 5041, and request that the
hospital take over the care of Mrs Carpenter.
In your answer:
sentences
CASE NOTES 23.2

NOTES:
CASE NOTES
Name: Mrs. Larissa Zaneeta Age 38-years-old
Family and social history
Marketing manager, married, one child
(fouryear-old boy).
Medical history
Unremarkable, no medications
11/07/05
Complains of tiredness, difficulty sleeping for
2 months due to work stress Plans another
child in
12 months, currently on oral contraceptive pill
(OCP)
O/E: Appears pale, tired and slightly restless
BP 140/80
No abnormal findings
Assessment: Stress-related anxiety
Plan: advised relaxation techniques, reduce
working hours, prescribe sleeping tablets tds
15/08/06 Stopped OCP 4 months earlier, still
menstruating
Worried
Sleep still difficult, work stress unchanged, not
possible to reduce hours O/E: Tired-looking,
slightly teary
Assessment: Work stress, growing anxiety
failure to conceive
Plan: discussed nature of conception – takes
time, patience discussed frequency sexual
intercourse discussed methods – temperature
/ cycle
18/01/07
Expressed anxiety re failure to conceive, says
she's "too old" sleep still a problem
O/E: crying, pale, fidgety
Vital signs / general exam NAD
Pelvic exam, pap smear
Assessment: as per previous consultation
Plan: 1-2 Valium b. d.
Suggested she re-present next week
accompanied by husband.
25/01/07
Mr. Zaneeta very supportive of having another
child
No erectile dysfunction, libido normal
Mrs. Zaneeta unchanged
O/E: Mr. Zaneeta normal
Plan: Check Mr. Zaneeta's sperm count
02/02/07
Sperm count normal
Plan: Refer for specialist advice
WRITING TASK
a letter of referral to Dr Elvira Sterinberg, a
gynecologist at 123 Church St Richmond 3121.
In your answer:
sentences
CASE NOTES 24.1

NOTES:
You are a nurse visiting Ms Styles at her home
who is taking self-care at home
Patient History
Name: Ms Patricia Styles
Age: 04/08/1955 (63 years)
MEDICAL BACKGROUND
Hypertension: diagnosed in 2012. on Carpinol
medicine, blood pressure
↑2014 (190 /100) Now BP under control
(140/90)
Diabetes Mellitus: diagnosed in 2009
(Type II), taking oral hypoglycemic
(Metformin+Glipizide)
Depression: diagnosed first in 2015. depressed
after her husband’s death, attends medical
counseling for mood swings and diabetes
mellitus management
SOCIAL BACKGROUND
Hobbies: walking, reading
Lives alone, no close relatives, her cousin
helps her sometimes
Medications
Carpinol-6.25 x2 times daily
Metformin-500mg x 2 times daily
Glipizide-10 mh x I daily
MEDICAL HISTORY
On 07/04/2018 she admitted in Green Valley
Hospital with chest pain (pleuritic).shortness
of breath(SOB), tiredness.
Management
Glucose monitored regularly, sugar and BP
(well controlled)
Blood test
ESR ↑(24), Creat ↑(2.0), Platelets ↓
(Stress/inflammation)
Oral throat swab: Type B influenza
Chest X-ray: Normal
Echocardiogram: Pericarditis
Diagnosis : Type B influenza plus pericarditis
Treatment: IV saline, Antibiotics
Discharged on 09/04/2018 advising further
follow up home visits.
She was on self-home care after discharge.
She was keeping well and the home nurse left
her 2 days ago.
14/04/2018 Home visit
Subjective: Ms Styles feels tired and has chest
pain
Examination: Unwell, Chest pain (↓ when
sitting), SOB, fatigue
Vital signs: Mild temperature (38), HR-122,
RR-28,
BP-180/90
Assessment: ?? Relapse Complication
pericarditis
Plan: Refer patient to Newtown Hospital
Emergency Department (nearest hospital)
Inform emergency doctor about patients o
Medical history o Medications o Past history
WRITING TASK
Write a referral letter for MS Styles to the
Emergency Doctor on Duty requesting urgent
assessment and management of her
pericarditis.
Address the letter to:
Emergency Doctor on Duty, Newtown
Hospital. Corner Street, Newtown 1104 In
your answer:
sentences
CASE NOTES 24.2

NOTES:
Today's Date
25/07/09
Notes
Vamuya Obeki was admitted through the
Children's Emergency Department for acute
meningoencephalitis as a result of a
complication following mumps.
Patient History
Address: 32 Sexton St,
Ekibin Phone: (07)
38485555
Date of Birth: 23 May 2005
Admitted: 15th July 2009 Gender: Male
Discharged: 25th July 2009
Country of birth: Sudan
Diagnosis: acute meningoencephalitis
Social History
Parents: Miri & Abdullah Obeki, refugees,
arrived in Australia in 2008. Employment:
Abdullah: Golden Circle pineapple factory,
shift worker
Miri: housewife
Accommodation: Recently moved to rental
accommodation GP: No family doctor
Sibling: 2 year old brother, Saeed
Language: Dinka, Arabic
Interpreter needs: Abdullah understands
spoken English but has limited written skills.
Miri has limited understanding of English.
Abdullah attends English classes.
Medical History
Parents state that both children had some
kind of vaccination at birth but the vaccination
record has been lost. Parents unaware of
vaccine for Mumps.
Discharge Plan
Appears to have fully recovered from mumps
and acute meningoencephalitis. Will need
advice on recommended vaccines for both
children. Will need neurological check-up.
WRITING TASK
Health Service, 41 Jones Street, Ekibin,
requesting follow-up of this family.
In your answer:
sentences
CASE NOTES 25.1

NOTES:
Ms Brown is a patient in your care. She is now
ready for discharge and will be transferred to
a rehabilitation hospital
Discharge Summary
Name: Ms Rose Brown
Age: 27 years
Admitted: 27/5/07
Diagnosis: Dislocated knee
Discharge: 18/6/07
Reason for admission: Dislocated knee
Treatment
After X-ray, it was determined that Ms Brown
had dislocated her left knee, The knee was
rested and strapped. Topical heat and cold
were used.
Social Situation
Ms Brown is a young woman with a mild
intellectual disability. She is a large woman,
and the extra strain her weight has put on her
leg has made her progress very slow, She lives
alone in a council flat, and as she is still unable
to walk confidently with crutches, it has been
decided that, at present she will not be able to
cope living alone. Her mother is willing to help
her, but is not able to help Rose into and out
of the shower by herself
Progress
Ms Brown is experiencing less pain but has
little strength in her leg. She is using a frame
at present. She lacks confidence with crutches
and requires at least one other nurse to assist
when she is using them
Discharge plan
Transfer to rehabilitation centre. Ms Brown
needs to continue to be seen by a
physiotherapist and to have water aerobics to
build up strength and stamina. She needs to
progress from the frame, to crutches, and
then to a walking stick Domiciliary care needs
to be contacted - a ramp and bathroom aids
will need to be placed in Ms Brown's home
before she returns
WRITING TASK
Using the discharge summary, write a nursing
letter about Ms Brown to the Director of
Nursing at the Repatriation General Hospital,
Daw Park.
In your answer:
sentences
CASE NOTES 25.2

NOTES:
You are the Charge Nurse on duty at the
Children’s Hospital. You have been caring for
this patient, Ann, an infant.
Patient Details
Name: Ann Ballard Age: 22 months
Next of Kin: Christine Ballard (mother)
Admission date: 16 March 2010
Discharge date: 22 March 2010
Diagnosis:
2nd degree burns to right trunk & arm
following accidental scalding with hot water
Family: Lives with mother and 4yr old brother
(Tom)
Background:
Mother (28 yrs) separated from husband 4
mths ago
Financial difficulties following separation
Housing: 3 bedroomed house in new housing
development
Family reliant on public transport
Socially isolated (Christine’s parents
interstate, has few friends) Christine
?depressed
Children spend alternate weekends with
father Medical history and medications:
Nil medications
Nil significant history
No known allergies
Management and progress during hospital
stay: 2 x daily Silvazine dressings to
affected area
IV fluids for 24 hrs post admission and then
oral fluids
Mother referred to hospital social worker
Medications: Prophylactic antibiotic cover &
analgesia
Discharge plan:
Daily Silvazine dressings
No discharge medications
Monitor mother’s mental state
Introduce to local supports (e.g., mothers’
group/activities, local childcare centre, etc.)
Appointment with local financial counsellor
(for financial problems)
WRITING TASK
as the Charge Nurse on duty, write a letter to
the family’s local maternal and child health
nurse, outlining relevant information and
requesting follow-up on discharge. Address
the letter to Greenville Maternal and Child
Health Centre, Main Rd, Greenville.
In your answer:
sentences
CASE NOTES 26.1

Patient: Susan Sarandon
DOB: 17-7-90
Marital status: Single
Family: Only child. Parents are still married
and living together. Pt is student in the 10th
grade.
First admitted:
13.9.05
Patient did not present to ER until 13.9.05, at
which time she displayed signs of peritonitis
and septic shock with a fever of 39°C
Discharge date: 8.9.05
Diagnosis: Ruptured appendix Peritonitis
Medical History:
Pt received adenoidectomy in 1987
Meds: Pt takes methylphenidate 10mg bid for
ADHD. May be continued.
Denies EtOH Tab use. Denies sexual activity.
Background:
Pt was on class trip to Perth from her school in
Bunbury when she developed peri-umbilical
pain and anorexia, beginning on 10.9.2005.
Initial pain followed by nausea. The pain then
migrated to the RLQ with a maximum over
McBurney's point
Management and Progress:
Labs showed leukocytosis with left deviation,
Hb of 13.1, Hct 41%. B-HCG was negative.
The patient was immediately given
ampicillin/gentamicin IV.
A U/S was carried out, which displayed free
fluid in the intra-abdominal space.
A standing CXR was also performed which
showed free air in the hepaticophrenic recess.
An emergent laparotomy was performed. A
perforation of the severely inflamed appendix
observed, along with intraperitoneal abscess
formation
Appendectomy performed; abscess drained
Pt transferred to SICU. Fever subsided.
Transferred to a normal room Ciprofloxacin IV
on Post op Day 1 →3 days
Discharge plan:
Pt is ready to be discharged to rehab centre.
She should re-present to this clinic on
1.10.05 for general assessment
Contact Dr. Brown if fever >38°C, signs of
infection or inflammation, SBP < 100 or 160
mmHg.
WRITING TASK
You are transferring Miss Susan Sarandon to
the Bunbury General Rehabilitation Centre.
Write a discharge summary to accompany the
patient.
In your answer:
sentences
CASE NOTES 26.2

TIME ALLOWED: READING TIME: 5 MINUTES
NOTES:
You are a nurse at Imperial County School,
Yarra Glen, where 90% of the students come
from villages close to thickly forested areas
where wildfires are common. Recently many
children had breathing issues due to smoke.
Take extra care to protect children from
wildfire smoke.
Children with asthma, allergies, or chronic
health issues may have more trouble
breathing when smoke or ash is present.
Before wildfire season:
Stock up on medicine. Store a 7 to 10-day
supply of prescription medicines in a
waterproof, childproof container to take with
you if you evacuate.
Buy groceries you won’t need to cook. Frying
or grilling especially can make indoor air
pollution worse.
Talk to your child’s healthcare provider.
If your child has asthma, allergies, or chronic
health issues plan how they can stay indoors
more often during a smoke event.
During a wildfire smoke event:
Pay attention to air quality.
Follow instructions about exercise and going
outside for “sensitive individuals.”
Check for school closings.
Remember that dust masks, surgical masks,
bandanas and breathing through a wet cloth
will not protect your child from smoke and
that N95 respirator masks are not made to fit
children and may not protect them.
Think about evacuating if your child has
trouble breathing or other symptoms that do
not get better.
If your child has severe trouble breathing, is
very sleepy, or will not eat or drink, reduce
their exposure to smoke and get medical help
right away.
After a wildfire:
Do not return home until safety assured.
Smoke remains indoor and outdoor days after
wildfires have ended. Continue to check local
air quality.
Children - should not do cleanup work;
Children away from ash. Make sure ash and
debris have been removed before you bring
your child back home or to school.
Avoid direct contact with ash and wash it off
child’s skin and mouth and rise it from eyes
immediately.
Contact healthcare provider if your child has
trouble breathing, shortness of breath, a
cough that won’t stop, or other symptoms
that do not go away.
Call 1800 022 222 or go right away to an
emergency department for medical
emergencies.
WRITING TASK
a letter to parents of the students (Address:
Parents, Imperial County School, Yarra Glen,
Melbourne - 3775.
In your answer:
sentences
CASE NOTES 27.1

NOTES:
Tracy Chapman is a 20-year-old single woman
with 3 children. She was admitted for an
Appendicectomy and has recovered. She is
ready to be discharged home.
 Name: Tracy Chapman
 Age: 20 years
 Admitted: 18 April 1990
 Discharged: 23 April 1990
 Diagnostics: Acute Appendicitis
 Operation: Appendicectomy 18 April 1990
Social background
Single with 3 children aged 18 months, 3 years
and 4 years
Lives in a rented flat with her children
The father of the children has no contact
Only income is the Single Mother's
Pension
Has several friends who all work fulltime
Tracy's mother is caring for the children but
will be returning to her home in the country
when Tracy comes home.
Nursing management and progress
Routine post operative recovery
Tolerating a light diet and fluids
Walking normally
Minimal pain relieved with 2 panadol 3 times
a day
Wound healed, sutures removed
Discharge plan
Rest
Moderate exercise
No heavy lifting or activity for 6 weeks
High protein diet
Observe wound for infection
Council "home help”
WRITING TASK
Tracy will require support and assistance to
manage her children when she returns home.
Using the information in the discharge
summary, write a letter of referral to the
community health nurse, Rae Willis, who will
assist Tracy at home.
In your answer:
sentences
CASE NOTES 28.1

NOTES:
Mrs Beryl Casey is a 72-year-old woman who
is being discharged from hospital to a
rehabilitation centre.
Patient: Mrs Beryl Casey
(DOB: 21/11/1941)
Marital status: Widowed (recently)
Family: 2 children – son lives locally &
daughter interstate.
Social: Lives alone in 2-bedroom house with
stairs to entrance. Son (married, 2 children – 6
& 8)
lives 20 minutes away – visits twice a week.
Enjoys gardening.
Medications: Anti-hypertensive (Ramipril)
10mg
Admission date:
4/02/14 at 1200hrs
Fainted getting out of bed & fell to the floor.
Found by son 2 hours later.
Diagnosis: X-ray – fractured left neck of femur
(# L NOF) post fall
Treatment:
Left hemiarthroplasty (Austin Moore hip
replacement); general anaesthesia Incision
closed with staples & 2x Exudrain Post
operation:
Intravenous (IV) therapy: 3 units packed cells
– with IV Lasix (furosemide) 40mg therapy
after each unit (intraoperative & post op)
Maintained IV therapy for 36 hrs, then ceased
and oral fluids encouraged Intravenous
antibiotics
(IVABs) – Cephazolin 1g t.d.s. for 3/7 – course
completed Vital signs:
BP hypotensive – 95/60, other obs.
within normal limits Antihypertensive
medication reviewed by Dr
Dose - now Ramipril 5mg daily
Pain management: Patient-controlled
analgesia (PCA) with Fentanyl for 36hrs – pain
relief – satisfactory. Commenced oral
analgesia 36hrs
Post op - Panadeine or Panadol 4/24 prn, Max
4 doses/24hrs
Wound management: Dressing √ Total of
600ml haemoserous fluid discharge from
Exudrains over 24hrs Drain tubes removed
48hrs post op (Day 2) Alternate staples
removed Day 5 and dressing Changed
Mobility & activities of daily living (ADLs):
Day 2 Sitting out of bed (SOOB) short periods,
full assistance
Day 3 Mobilising with pick-up frame
(PUF) & 2-person assist
Day 4 Uneventful
Day 5 Mobilising short distances with PUF & 1-
person assist Abduction pillow when resting in
bed (RIB) Anti-embolic stockings in situ for 14
days ADLs – full assistance
Day 6 Uneventful day Preparing for discharge
Discharge plan:
Day 7 (1100hrs) Discharge to the
Rehabilitation Centre Discharge medications –
Ramipril 5mg daily, paracetamol 1g qid prn
Family to be notified of transfer Hospital
transport arranged for 1100hrs
Day 8 Repeat check of hemoglobin (Hb) levels
Monitor BP b.d., for 3/7, due to adjustment in
anti-hypertensive meds Assess for rehab
therapy (inpatient & on return home)
Day 10 Removal of remaining staples, wound
can remain exposed Afterwards
WRITING TASK
write a discharge letter to the Nursing Unit
Manager, The Rehabilitation Centre,
Waterford.
In your answer:
sentences
CASE NOTES 29 (4)

MINUTES
NOTES:
Today’s Date: 27/12/2017
You are a registered nurse in the Coronary
Care Unit, St Vincent’s Hospital Melbourne.
Derek Shepherd is a patient in your care.
Patient Details
Name: Derek Shepherd
DOB: 13 September 1970
Address: 108 Queen Street Melbourne
Admitted: 20 December 2017
Date of discharge: 27/12/2017
Diagnosis Obstructive coronary artery disease
Operation Coronary artery bypass grafts (x 4)
Social History
Never married
Lives alone in own home
Works as a Business Development Manager at
a bank
Medical History
Constipation occasionally- takes isabgol for
relief
Smokes 5-6 cigarettes/day
Alcohol: 2 x 300 ml bottles beer/day
Ht 185 cm Wt 102 kg (BMI- 29 Overweight)
Dietary habits: sausages, deep fried chips,
pizzas, pastas,
Allergic reaction to nuts
20/12/2017
History of presenting complaint: severe chest
pain, extreme tightness in chest – felt like
someone is standing on his chest, heaviness in
both forearms, shortness of breath • Chest
pain started 3-5 months ago, has been
increasing in intensity since, got worse on
exertion
Diagnosed with Obstructive Coronary artery
disease
21/12/2017
Operation coronary artery bypass grafts (x4)
Routine postoperative recovery
Pain/Discomfort managed
23/12/2017
Constipation related to decrease response to
urge to defecate secondary to surgical
procedure – no stool for 2 days
Pt. given isabgol for constipation
Pain – 5/10
PT commenced- Rev. by Physio
Position change every 4 qh
24/12/2017
Knowledge deficit re diagnosis, surgical
procedure, seemed confused- educated
regarding event
PT – continued
Low fat diet
No complaints of constipation
26/12/2017
Pain 2/10
Pt. walking well – routine visits by PT
Pt. explained post discharge instructions
(resume work after 4 wks., avoid
travelling/strenuous exercises till 6 wk.,
follow-up after 6 wks., medications)
Pt. counselled on changes to lifestyle (cease
smoking- referred to Quit line, decrease
alcohol, reduce weight, low-fat diet, exercise
regime)
Pt. has knowledge and understanding of
diagnosis, procedure, long term rehabilitation
– worried about future as evidenced by
patient verbalization “I don’t know how I will
cope with my job and finances, I might be
fired if I don’t go to work for a month” – refer
to Cardiac Rehab. S/W for support
Wound healing well – daily dressing change
Pt. educated re smoking cessation – referred
to Quit line
Pt. educated re decreasing alcohol
Low fat diet
Medications: Aspirin ½ daily, Vicodin q4
Discharge Plan
Returning Home – avoid strenuous activities,
travelling till 6 wks., resume work after 4 wks.
Follow-up visit after 6 weeks • Refer to District
Nurse – wound management, monitor
medications, diet, temp.
Call Hospital if wound swollen, temp rises
above 101-degree F
rehabilitation exercise program- increase
physical strength, gradually increase physical
activity
Low-fat diet after discharge
pt. Requested more information on simple
low-fat recipes that can be prepared at home
Refer to local Social Worker at Cardiac Rehab.
for support to pt. for applying leave from
work, financial assistance
WRITING TASK
write a letter to Dr Addison Burke, Dietician,
Suite 1, 348, 5th floor, Church Street,
Melbourne requesting information on dietary
guidelines for Mr. Shepherd. The information
should be sent to his home address.
Expand the relevant case notes into complete
sentences
The body of the letter should not be more
than 200 words
WRITING TASK
write a letter to Ms. Christina Yang, Senior
Social Worker, Cardiac Rehabilitation
Program, Elizabeth Hospital, 43-47 King Street,
Melbourne to provide support service to the
patient to help him re-adjust to normal life.
WRITING TASK
Using information given in the case notes,
write a referral letter to Ms. Patricia Welsh,
Physiotherapist, 305, Third Floor, Central Park,
Melbourne requesting her to supervise the
patient’s home-based exercise program.
WRITING TASK
write a letter to the Ms. Anna Thompson,
District Nurse, requesting follow-up care for
this patient.
CASE NOTES 30 (3)

MINUTES
NOTES:
You are the registered nurse in the Cardiology
Unit at St Luke’s hospital, Adelaide. Ms. Kylie
Weiss is a patient in your care.
Name: Ms. Kylie Weiss
D.O.B.: 21/05/1952
Address: 8758, Pulteney Street,
Adelaide, SA, 5000
Date of admission: 07/07/2017
Presenting complaint: BIBA (Brought in by
ambulance) – 2 hour history intermittent
discomfort jaw/heaviness in both forearms,
constant discomfort
IV access in ambulance, 10 mg IV Morphine on
route,
Aspirin 300 mg chewed, Glytrin spray x 3 ECG
showing ST elevation
Diagnosis: Myocardial Infarction
Medical History: Weight: 85 kilograms,
Height: 170 cm – Overweight (BMI-29)
Ex-smoker – 1994
Mild osteoarthritis
Mild asthma – no exacerbations within last 5
years
Dyslipidaemia- (Raised cholesterol) – not
treated
Medications: NIL
Occupation: Works as a taxi driver, mixed
shifts
Dietary Habits: Eats fast food- fries,
hamburgers, doughnuts, ice cream, non-
drinker
Family History: Brother- Coronary artery
bypass grafting (CABG) at 70 years
Sister MI(Myocardial Infarction) at 60 years,
Mother-angina
Social History: Marital status: Married with
one daughter Husband-Peter Weiss, 67 years,
retired, aged pensioner
Medical Treatment: Emergency

Angioplasty performed
ST Segment elevation on ECG – Direct stenting
to proximal LAD
Echocardiogram –Ejection fraction 35%
Pain/Discomfort – managed
Fasting Bloods (Lipids, Diabetes, TnI(proteins
troponin),
CBC(complete blood count), Biochem)- High
Cholesterol levels
Nil further pain/discomfort, Cardiac status
stable Pt. seemed confused re diagnosis,
reality of near death experience -Educated re
event, MI diagnosis and modifications to risk
factors
(Cholesterol, wt. loss)
R/v(review) by Physiotherapist – cardiac
exercise program provided
R/v by dietician – diet for weight loss &
reduced cholesterol levels
Concerned about being unable to manage
home on her husband’s pension -S/W (Social
Worker) input required
09/07/2017 Preparing for discharge
Discharge medications: Atorvastatin 40 mg
OD,Metoprolol 23.75 mg OD
Cilazipril 0.5 mg OD, Aspirin 100 mg OD,
Ticegralor 90 mg BD
Glytrin spray prn for chest pain
Discharge plan: No driving for 6 weeks.
Refer to Cardiac Rehabilitation Nurse
Specialist –compliance with risk factor
management (wt. loss, low cholesterol diet),
medications, education re about MI and its
management Refer to Occupational Therapist
– to provide guidelines for returning to work,
driving and normal daily activities,
Refer to Social Worker – due to inability to
work for 6 weeks
6-week recovery from MI, assess eligibility for
sickness allowance/ benefits from the
Australian Government Department of Human
Services.
WRITING TASK
write a referral letter to Ms. Nina Gill, Cardiac
Rehabilitation Nurse Specialist, Cardiac
Rehabilitation Clinic, 41, Jones St, Adelaide
outlining important information.
WRITING TASK
a referral letter to Mr. Barney
Dyer, Occupational Therapist, Home
Occupational Therapy Services, 85 Flinders
Street, Adelaide requesting him to visit Ms.
Weiss at home and provide guidelines for
returning to work, driving and normal daily
activities.
WRITING TASK
write a letter to Ms. Linda Gold, Social
Worker, Gold Social Services, 478, Collins
Street, Adelaide requesting her to visit Ms.
Weiss at her home and assess her eligibility
for receiving a sickness allowance or other
benefits from the Australian Government
Department of Human Services.
In your answer:
sentences
approximately 180–200 words
MODEL LETTERS
NOTE: Do not copy this model letter. Use it as

a comparative reference 38AFTER you have
written your own letter. Copying the letter will
not improve your writing skills!
NOTE: Do not copy this model letter. Use it as
a comparative reference AFTER you have
written your own letter. Copying the letter will
not improve your writing skills!
Nursing Sample Response 24
Grace Gerome
Your choice Home Care Agency
Leichhardt NSW Australia
(Today’s date)
Dear Dr. Grace Gerome
Re: Vanessa Stanley, 85 years old
Mrs. Stanley is being discharged from our
hospital into your care today according to
doctor’s recommendation, in view of her
weakness and physical inability.
She is a patient who lives alone and has no
children, which puts her in a vulnerable
situation; although her neighbour, Mariya,
visits her house quite regularly. Her medical
history reveals the following information:
presence of bilateral lower extremity edema
(cellulitis of lower extremities), renal
insufficiency, hypercholesterolemia and
obesity, incontinence of bladder and bowel at
times.
For several years, the patient has been
suffering from BP related problems as well.
Slow blood flow in the veins
(especially of the legs) is also a part of her
medical history which seems to be prevailing.
She is able to move around with her walker,
although she tires easily and finds it difficult to
stay focused due to her age.
I would like to make a request for your agency
to appoint someone for personal care of the
patient, as she cannot take care of herself. She
can be contacted on the following number:
+61 34974 5659
Reports detailing her medical history and a list
of her prescriptions are attached to this letter
for your information. Please, do let me know if
you require any further information or have
any queries.
Yours sincerely,
Heather Donald Charge
Nurse
Dr Peter Daniel 435

Fitzgerald St North Sydney Australia
(Today’s date)
Dear Dr Peter Daniel
Re: Harley Simon, Age 55 years old

Harley Simon is a patient who is being
discharged from our hospital into your care
today. He was admitted into our hospital on
22nd of January 2018, following complaints of
high fever, body pain, headaches, discomfort
and poor appetite.
His medical history shows the presence of

early dementia (which has been progressing
since 2010, as per his MD). He is also a patient
of BP (noted in the year 2008) and blood sugar
(noted in the same year). In addition, he is
suffering from obesity, HTN, DJD and
depression, and he is allergic to peanuts. The
patient ambulates with a cane and contact
guard. It has been observed that he is often
active during the night and then wants to
sleep during the day; this could be linked
to his depression.
As the patient’s health and symptoms have

been improving, he has been discharged early.
Blood pressure was noted at the time of
discharge as 180/110 mm Hg and his blood
sugar levels were normal. He was advised to
take paracetamol (500 mg - 3 times in a day)
and the option of aspirin was discussed with
him (500 mg - to be given if there is an
increase in pain levels).
Reports on his medical history are attached

here. Please, do let me know if you require
any more information about the patient or
have any further queries.
Yours sincerely,
Deborah Daniel
Charge Nurse
Prince of Wales Hospital
Dr Alexander Samuel 36
Pacific Hwy
St Leonards NSW
Australia
(Today’s date)
Dear Dr Alexander Samuel

Re: Agnes Moore, Age 53 years old
Agnes Moore is a patient who was admitted

into our hospital on the 2nd of February 2018
due to problems with breathing. She was not
able to breathe properly at home so she was
rushed into hospital. The BP noted at the time
of admission was 170/110 mm Hg. On
assessment of the problem, the doctor
prescribed the use of Lisinopril. Her condition
soon became normal and she was able to
breathe without a struggle.
Her medical history reveals that she has been

suffering from hypertension and diabetes
since 1996. Also, the peripheral artery disease
of the legs was noted in the year 2006. The
patient’s left foot turns out on ambulation -
her husband stated that she has a weak ankle
and chronic burning pain in it. The patient is
taking a prescription for hypertension and
diabetes and
the doctor has recommended the same
prescription for her new symptoms.
The patient was well at the time of discharge

and the reports on the tests that were
conducted here (blood test and urine test),
medical history of the patient and the
prescribed medicine are attached to this letter
for your perusal. Please, do let me know if you
would like to know any further details about
the patient.
Yours sincerely,
Samantha Nixon
Charge Nurse
Bloombay Hospital
Dr. Kendrick Johnson St. Vincent’s Hospital

Australia
(Today’s date)
Dear Dr. Kendrick Johnson

Re: John Williams, Aged 68 years old
Charles Gardiner is a patient who was

admitted into our hospital on the 10th of
April, 2018. The symptoms he was presenting
were pains, aches, discomfort and tightness
across the front of his chest. The BP noted at
the time of admission was 170/110 mm Hg
and the patient showed signs of angina.
After a thorough assessment, the condition

was confirmed (myocardial perfusion
scintigraphy confirmed the diagnosis of
angina). Without any further delay, an
operation was performed on the 18th of April
2018. Please note that John Williams is a BP
patient as well.
The general condition of the patient can be

stated as follows: he wears glasses; he is
somewhat hard of hearing; his speech is clear
but has mild dysphasia; he
ambulates with a cane or rolling walker
independently but sometimes he may need
supervision or a contact guard on stairs. He
also wears disposable undergarments; he is
continent of bowel, but incontinent of
bladder.
The patient was well at the time of discharge.

Reports on the medical history of the patient
and the prescribed course of medicine are
attached here with this letter.
Please, do let me know if you would like to

know any further details about the patient.
Yours sincerely, Hannah Micheal

Charge Nurse
Royal Perth Hospital
Dr. Luke Davies Royal

Perth Hospital 56 Churchill
Ave Subiaco WA Australia
(Today’s date)
Dear Dr. Luke Davies

Re: Hannah Morris, DOB 14 May 1973
Hannah Morris is a patient who is in receipt of

health care services from our agency. She is a
patient of diabetes mellitus and hypertension.
Just recently, she complained of a severe
headache and, since then, it has been
recurring episodically. The pounding headache
began approximately two weeks ago and it is
localized to both frontal areas. Apart from
this, patient had 3 to 5 episodes of giddiness
during household chores.
This pain is not associated with nausea,

vomiting, or lightsensitivity and often goes
away after the patient takes overthe-counter
analgesics. I am pleased to report that no
changes in her vision have been noted and
there is no history of similar headaches.
Neither is there any family history of
intractable headaches.
However, the patient has suffered two

episodes of impaired consciousness, during
the last 2 weeks. The first one happened while
she was cooking (this was around 10 days ago)
and the second while she was driving (just two
days ago). During these episodes, no jerking of
the limbs occurred and neither did any
incontinence. Upon recommendation from
the doctor, the patient underwent a physical
examination and a neurological examination;
she also underwent necessary lab tests.
Reports on the medical history of the patient
and the results of the tests conducted are
attached to this letter for your reference. I
would like to request that you look into this
case. Please, do let me know if you require
any further details about the patient.
Yours sincerely,
Susan Hosbel
Senior Nurse
Santa cruz Health Care Agency
02/02/2018
Ms. Meredith Stevens
Charge Nurse
Holy Heart Hospital
119 Red Sparrow Road
Docklands
Melbourne
Re: Ms. Paula Anderson; DOB: 19/05/1954
Dear Ms. Stevens
I am writing to refer Ms. Anderson who has
been diagnosed with colon cancer and is being
transferred to your facility today for
colostomy on 05/02/2018.
To prepare Ms. Anderson for the surgery, she
needs to reduce her fluid and diet intake;
consequently, there is a possibility of the
patient becoming dehydrated. She can be
given a low-residue diet today followed by
fluids only the next two days, and you are
requested to ensure a variety of acceptable
drinks. It is imperative that Ms. Anderson eats
and drinks nothing from midnight on the day
of the operation.
To ensure that the surgeon can have clear

access to the operation site, rectal wash-outs
should be given each evening before the
operation so that her bowel is clear of all
faecal matter. Moreover, Ms. Anderson is
worried about the consequences of
colostomy; hence, you are requested to meet
her on 04/02/2018 to discuss anticipated
problems at home following the surgery and
educate her on managing at home. It is also
advisable to guide her family on how they can
be involved in Ms. Anderson’s care at home.
The patient’s medical reports are attached to
this letter. Please contact with any questions.
Yours sincerely
(Your name here) Nursing Sample
Response 49
27/12/2017
Dr Addison Burke
Dietician
Suite 1, 348, 5th floor
Church Street Melbourne
Re: Mr. Derek Shepherd; DOB: 13/09/1970
Dear Dr. Burke
The purpose of this letter is to solicit low-fat
dietary guidelines for the above- captioned
patient who presented to us on 20/12/2017,
was diagnosed with obstructive coronary
artery disease, and underwent a coronary
artery bypass graft under our care. He is being
discharged today.
His risk factors include being overweight, due
to a diet primarily consisting of fat-rich foods
like sausages, pasta, pizzas, and deep-fried
chips.
His height is 185 cm, and he currently weighs

102 kg. Moreover, he is a smoker and smokes
about 5-6 cigarettes a day. Further, he drinks
two 300 ml bottles of beer regularly. His
medical history is significant for intermittent
bouts of constipation that is relieved with
isabgol, and allergy to nuts.
Mr. Shepherd has progressed well after the
surgery. He has been educated regarding
smoking cessation and reducing his alcohol
intake. Moreover, he has been advised to lose
weight through exercise and diet; therefore,
he has requested detailed advice on simple
low-fat recipes that can be easily prepared at
home.
Therefore, it would be greatly appreciated if
you could send this information to his
address, attached to this letter.
Should you have any questions, please do not
hesitate to contact me.
Yours sincerely
(Your name here)

27/12/2017
Ms. Christina Yang,
Senior Social Worker
Cardiac Rehabilitation Program
Elizabeth Hospital
43-47 King Street Melbourne
Re: Mr. Derek Shepherd; DOB:13/09/1970
Dear Ms. Yang
I am writing to refer Mr. Shepherd who is
recovering from a heart bypass surgery and
requires your assistance to apply for financial
aid and 4-week leave from work. He was
admitted on 20/12/2017 and is being
discharged today.
Postoperatively, Mr. Shepherd has progressed
well and made an encouraging recovery;
nevertheless, he has been advised to get
sufficient rest and recommence work after
four weeks.
Mr. Shepherd works as a Business
Development Manager at a bank and is
worried about maintaining his employment
and taking time off work for a month.
Additionally, he is concerned about
experiencing financial strains owing to a
potential reduction in income until he
resumes work.
Given the above, it would be highly
appreciated if you could inform his employer
of his situation and arrange a 4-week
employment leave for him. Moreover, please
assist him in applying for financial aid to
minimize his stress during the recovery
period.
Enclosed herewith is the supportive
documentation regarding patient’s medical
condition. Should you have any further
queries, please do not hesitate to contact me.
Yours sincerely
(Your name here)
27/12/2017
Ms. Patricia Welsh
Physiotherapist
305, Third Floor
Central Park Melbourne
Dear Ms Welsh
This letter will introduce the above-captioned
patient who is recovering from a coronary
artery bypass graft surgery and requires
ongoing support from you to continue his
cardiac rehabilitation exercise program at
home. He lives alone and is being discharged
today.
He presented to us on 20/12/2017 and
underwent an uneventful surgery.
Postoperatively, he was reviewed by a
physiotherapist who commenced him on an
exercise program to promote strength and
healing; consequently, his ambulatory status
has improved, and he can mobilize
independently. He has attained significant
recovery and has been recommended to lose
weight to ensure good general health. His
height is 185 cm, and he currently weighs 102
kg.
Given the above, it would be greatly
appreciated if you could visit him daily to
ensure his compliance with the recommended
exercise regime and assist him in regaining his
physical strength. Of note, he has been
advised to refrain from strenuous activities for
six weeks; therefore, please ensure that he
increases his physical activities gradually.
Should you have any further queries, please
do not hesitate to contact me.
Yours sincerely
(Your name here)

27/12/2017
Ms. Anna Thompson
District Nurse
Dear Ms. Thompson
This letter will introduce Mr. Shepherd who is
recovering from a coronary artery bypass
surgery. He was admitted to hospital on
20/12/2017. He lives alone and requires
follow-up care from you following his
discharge today.
During hospitalization, the patient responded
well to the adopted treatment plan which
focused on adequate pain-relief,
postoperative physiotherapy, patient
education regarding the risk-factor
management, and regular wound dressing.
It would be greatly appreciated if you could
monitor his progress to ascertain if any risks
are present. Kindly call us immediately if his
body temperature rises above 101 degrees or
the wound site is swollen or infected.
Additionally, please continue the wound
management and ensure compliance with the
discharge medications and low-fat diet plan.
His medication chart is attached to this letter,
and the diet plan will be sent directly to his
house by the dietician.
Worthy to note, he needs to abstain from

traveling and participation in strenuous
activities until his follow-up appointment
scheduled in 6 weeks’ time. He will be able to
resume work after four weeks, and he needs
to ensure adherence to the post-discharge
instructions for which appropriate referrals
have been made.
Should you have any further queries, please
Yours sincerely
(Your name here)
27/12/2017
Ms. Anna Thompson District Nurse
Dear Ms. Thompson
The purpose of this letter is to request regular
home visits for the above- captioned patient
who presented to us on 20/12/2017 and
underwent a coronary artery bypass surgery
under our care. He is being discharged today
and lives on his own.
He has made remarkable progress in the
hospital; nevertheless, additional medical care
is needed from until his follow-up
appointment in six weeks’ time.
His wound has been healing well, and you are
requested to change the dressing on the
wound site daily. Moreover, please monitor
him closely, and notify us immediately in case
his wound site is swollen or his body
temperature exceeds 101 degrees. Further,
please ensure adherence to the discharge
medications, which include 1/2 Aspirin daily
and Vicodin every 4 hours.
Besides that, could you also ensure that the
patient is compliant with the low-fat diet plan,
which will be directly sent to his by the
dietician? Of note, he has been advised to
refrain from traveling and rigorous activities
for six weeks, but he will be able to resume
work after four weeks. He has been counseled
on risk-factor management after discharge,
and appropriate referrals have made to
support his recovery.
Please contact me with any questions.
Yours sincerely
(Your name here)
15/02/2017
Ms. Samantha Golden
Diabetes Specialist Nurse
Victoria Health Education Centre
Suite 548 4th floor
34 Collins Street Melbourne
Re: Ms. Elizabeth Carmel; DOB: 02/04/1975
Dear Ms. Golden
I am writing to refer Ms. Carmel, a diabetic
patient, who was admitted in an unconscious
state on 13/02/2017, was diagnosed with
diabetic ketoacidosis, and is being discharged
today. She requires a home visit for education
on diabetes management to reduce the risk of
a future diabetic emergency.
Her husband reported that she was diagnosed
with diabetes two years ago but is poorly
compliant with timely administration of
insulin. He also said that she consumes fat-
rich diet and a moderate quantity of alcohol
and has an irregular eating pattern. Her BMI is
above the ideal range (33), and she engages in
little physical activity.
While hospitalization, she responded well to
the treatment and was educated on the role
of timely doses of insulin and diet to control
her diabetes. Her condition has stabilized, and
she will be reviewed after 15 days.
Given Ms. Carmel’s history and recent
emergency, please guide her on how to
maintain metabolic control in the future as
well as the dangers of hyperglycaemia
resulting from excessive food intake, eating
the wrong kinds of food, and decreased
activity levels. Further, she will also need to
know the methods of testing urine for
ketones.
Yours sincerely
(Your name here)
15/02/2017
Ms. Angelina Hobbs
Dietician
Salona Health Clinic
Suite 404, 11th Floor Bourke Street
Melbourne.
Dear Ms. Hobbs
The purpose of this letter is to request low-fat,
diabetic guidelines for Ms. Carmel, a diabetic
patient, who was admitted to hospital on 13
February in an unconscious state owing to
diabetic ketoacidosis. Her condition has
stabilized, and she is being discharged today.
Ms. Carmel has had poorly-controlled
diabetes for two years, and her risk factors
include non-compliance with timely
administration of insulin and consumption of a
fat-rich diet including pancakes, 3-4 cups of
coffee, cheese omelette, muffins, biscuits, fish
and chips, fried chicken, and sweetened
juices. She also consumes 1- 2 glasses of wine
daily and whiskey occasionally. Moreover,
little physical activity compounded with the
wrong choice of foods and erratic eating
patterns have led her to become obese (BMI
33).
With treatment, her condition has improved,
and adequate referrals have been arranged to
increase her knowledge of precipitating
factors to avoid recurrences in the future.
advise a low-fat, diabetic dietary timetable for
Ms. Carmel to correct her nutrition imbalance.
She has also requested information on meal
choices outside the home. This information
needs to be sent directly to her home address.
Yours sincerely
(Your name here)

15/02/2017
Ms. Pamela Wilkins District Nurse
Dear Ms. Wilkins
I am writing to request home visits to monitor
Ms. Carmel’s condition following her
discharge today. She was admitted on 13
February in an unconscious state owing to
diabetic ketoacidosis.
Ms. Carmel has had diabetes for the past two
years with poor adherence to timely insulin
administration. Moreover, she consumes a
fat-rich diet with moderate alcohol
consumption and has irregular eating habits.
She engages in little physical activity and is
obese (BMI 33).
While hospitalization, she has progressed well
and has been educated on the importance of
diabetes management. The referrals to the
dietician for a diet schedule and the
physiotherapist for a weight-loss program
have been arranged, and a home visit by a
diabetes specialist nurse has been requested
to educate the patient on self-care at home.
Kindly reinforce the education already
provided in the hospital regarding the
necessity of not missing insulin doses, eating
meals at regular intervals, and maintaining a
gap of 30 minutes between insulin injections
and mealtimes. Additionally, please ensure
that the patient is compliant with
recommended diet timetable and weight-loss
program. In case she is unable to retain any
fluids, please contact us immediately. Of note,
she is due for a review after 15 days.
Please contact me with questions.
Yours sincerely
(Your name here)
15/02/2017
Ms. Alka
Physiotherapist
GNB Medical Centre
45-50 Sacramento Road
Coburg
Dear Ms. Alka
I am writing to refer Ms. Carmel, an obese
woman, who was admitted on 13 February in
an unconscious state owing to a diabetes-
related complication. She is being discharged
today, and she requires home visits from you
for a weight- loss program.
Up until now, her lifestyle has comprised of
little physical activity in her routine. She goes
for a slow walk one to two times in a week.
Moreover, she consumes a fat-rich diet;
consequently, she is obese, and her current
BMI is 33. Owing to these lifestyle habits, she
has had poorly managed diabetes for the past
two years.
With treatment, her condition has improved;
however, she needs to lose weight and
increase physical activity for better
management of diabetes and to reduce the
risk of diabetes-related emergencies in the
future. A dietician has been requested to send
low-fat, diabetic guidelines to her house
directly, and she is due for a review in 15 days’
time.
visit Ms. Carmel at her house and initiate an
exercise program to promote her weight-loss.
Moreover, please assist her in gradually
increasing physical activity to achieve better
diabetes control.
Yours sincerely
(Your name here)
23/06/2017
Ms. Prabha
Shrishti Nursing Home Care Agency
Sydney
Re: Mrs. Anita Ramamurthy; aged 59
Dear Ms. Prabha
The purpose of this letter is to request a home
visit for Mrs. Ramamurthy, a diabetic patient,
who needs education on self-monitoring her
blood glucose levels and administering insulin
injections. She has had type-2 diabetes since
2010 and has poor adherence to its
management.
She presented to us on 18/06/2017 and was
diagnosed with acute appendicitis. During
hospitalization, the adopted treatment plan
included conservative management and plan
for interval appendectomy six weeks later. Her
recovery has been encouraging/promising so
far, and she is being discharged back home
today.
She has been educated regarding the role of
nutrition in effectively
controlling her diabetes by the dietician.
Moreover, the hospital endocrinologist has
advised her to chart blood glucose daily and
control her sugar levels with insulin injections
until her follow-up visit scheduled on
30/06/2017. She is accepting of this but feels
that she is not skilled at doing these herself.
Consequently, at her husband’s request, I am
requesting you to visit her at her home and
provide necessary guidance so that she can
competently perform these procedures.
Enclosed herewith are all pertinent details.
Should you have any further inquiries, please
Yours sincerely
(Your name here)

23/06/2017
Ms. Prabha
Shrishti Nursing Home Care Agency
Sydney
Re: Mrs. Anita Ramamurthy; aged 59
Dear Ms. Prabha
I am writing to request a home visit for Mrs.
Ramamurthy, a diabetic patient, who needs
education on self-monitoring her blood
glucose levels and administering insulin
injections. She presented to us on 18/06/2017
and was diagnosed with acute appendicitis.
She has recovered significantly, and her
appendectomy is scheduled after six weeks.
She is being discharged today.
She has been suffering from type-2 diabetes
since 2010 and has poor adherence to its
management. During hospitalization, she has
been educated regarding the role of nutrition
in effectively controlling her diabetes by the
dietician. Moreover, the hospital
endocrinologist has advised her to chart blood
glucose daily and control her sugar levels with
insulin injections. She has been asked to
present her blood glucose chart during her
follow-up visit scheduled on 30/06/2017. She
is willing to perform these procedures but
lacks the confidence to do these
independently.
Therefore, her husband has requested a home
visit for the demonstration of blood glucose
monitoring and taking insulin injections at
home. It would be greatly appreciated if you
could visit her and provide the requisite
instructions so that she can perform these
procedures on her own.
Enclosed herewith are all pertinent details.
Should you have any further inquiries, please
Yours sincerely
(Your name here) Charge Nurse

23/06/2017
Ms. April
Dietician
258 George Street
Sydney
RE: Ms. Anita Ramamurthy; 59-year-old
businesswoman
Dear Ms. April
The purpose of this letter is to request
information about low-fat, diabetic diet for
Ms. Ramamurthy who presented to us on
18/06/2017 and is being discharged back
home today. She has been treated for acute
appendicitis while hospitalization and is
scheduled to undergo interval appendectomy
in 6 weeks’ time.
Socially, she leads a sedentary lifestyle and
consumes a fat-rich diet consisting of fast
foods and sugary drinks. Additionally, her BMI
is remarkably high (33). Her medical history is
remarkable for hypertension and poorly-
controlled diabetes type 2.
Upon admission, she was managed
conservatively with intravenous antibiotics
and other supportive treatment. Additionally,
she was assessed by a dietician, who educated
her on the role of proper nutrition, and an
endocrinologist for ongoing management of
her diabetes. Following her discharge, she has
been advised to ensure adherence to a low
fat, diabetic diet.
She has requested detailed advice on dietary
guidelines, including simple recipes that can
be prepared at home, for losing weight as well
as controlling her diabetes. It would be greatly
appreciated if you could send the requested
information to her home address.
Thanks for considering this request and
sending her this information at the earliest.
Yours sincerely
(Your name here)
Charge Nurse
23/06/2017
Mr. Krishnan Ramamurthy
648, Bourke Street Sydney
Dear Mr. Ramamurthy
I am writing regarding Ms. Anita
Ramamurthy’s future care requirements after
she has been discharged. Her recovery has
been encouraging so far but continued
monitoring and attention will be necessary.
Ms. Ramamurthy made significant progress in
her condition during her stay, and her
infection is controlled now. Her surgery has
been scheduled after six weeks. Following her
discharge, she has been advised to ensure
compliance with a low-fat, diabetic diet. Ms.
Ramamurthy has requested more information
about dietary guidelines and simple recipes
which will be directly sent to your house by a
dietician. It is also necessary that she avoids
travelling or rigorous activities.
Besides that, she needs to chart blood glucose
daily and control her sugar levels with insulin
injections. We are aware of your wife’s
concern regarding this; therefore, a home visit
by a nurse has been arranged for instructions
on correct technique of these procedures. In
case she experiences any persistent pain or
fever, please contact us immediately at
03492250.
Of note, the blood glucose chart needs to be
presented during the follow-up consultation
scheduled next week on 30/06/2017 at 3 PM.
We hope Ms. Ramamurthy continues to make
a speedy recovery.
Yours sincerely
(Your name here)
Charge Nurse
31/01/2017
Dr John Dyer
West Suburban Eye Care Centre
396 Remington Boulevard
Suite 340
Romaville
Re: Mr. Tej Singh Randhawa; DOB:
09/09/1976
Dear Dr Dyer
I am writing to request an assessment and
further management of Mr. Randhawa who is
presenting with signs and symptoms
consistent with Horner’s syndrome.
Initially, he presented to us on 10/01/2017
complaining of rhinorrhea and headaches. At
that time, it was suspected that sinus pressure
was causing the headaches; consequently, he
was treated for infectious sinusitis.
He returned two weeks later with
deteriorating symptoms. At this subsequent
visit, he complained of excruciating, right-
sided, throbbing headaches that occurred
intermittently and did not subside despite
attempts to rest. Additionally, he reported of
concurrent aching teeth and previously
described rhinorrhoea. A diagnosis of a cluster
headache was made, and the patient was
prescribed acetaminophen and non-steroidal
anti-inflammatory medications.
On his last visit two days ago, he presented
along with his wife who noted that his right
eye (ipsilateral to the headaches) seemed
“droopy and sunken” and that his face flushed
preceding and during the headaches.
Moreover, the pupil of his right eye
constricted in darkness, and he had decreased
sweating on the right side of his face.
appreciated if you could assess, examine, and
treat the patient as deemed appropriate.
Please contact me in case you have any
questions.
Yours sincerely
(Your name here)

Head Nurse
31/01/2017
Dr. John Dyer
West Suburban Eye Care Centre
396 Remington Boulevard
Suite 340
Romaville
Re: Mr. Tej Singh Randhawa; DOB:
09/09/1976
Dear Dr. Dyer
I am referring the
above-captioned patient who
is
demonstrating/presenting/manifesting/exhibi
ting signs and symptoms suggestive
of/indicative of/consistent with Horner’s
syndrome.
Mr. Randhawa has attended our clinic thrice
over the past three weeks, during which time
he has had several episodes of severe right-
sided headache.
He first presented on 10/01/2017 with
complaints of a headache and rhinorrhoea. On
that day, he was prescribed Augmentin based
on a diagnosis of infectious sinusitis.
He returned two weeks later with complaints
of dressing right-sided throbbing headaches,
which occurred periodically and were not
relieved by rest. Additionally, rhinorrhoea had
persisted, and headaches were accompanied
by aching teeth. The symptoms were
suggestive of a cluster headache;
consequently, he was commenced on
acetaminophen and non- steroidal anti-
inflammatory medications.
Two days ago, accompanied by his wife, he
presented again as his right eye seemed
‘droopy and sunken.’ Moreover, his wife
reported that his face flushed before and
during headaches. An examination that day
revealed decreased sweating on the right side
of his face and that his right pupil constricted
in darkness.
appreciated if you could assess, examine, and
treat the patient as deemed appropriate.
Yours sincerely
(Your name here)
Head Nurse

02/07/2017
Ms. Susan Parry
Charge Nurse
Helping Hand Rehabilitation Centre
Eagle Vale
Sydney NSW
Re: Mrs. Nina Davies; DOB: 25/12/1943

Dear Ms. Parry
I am writing to request rehabilitative care for
the above-captioned patient, a patient of
osteoporosis since 2015, who was admitted to
our hospital on 28/06/2017 with a fractured
left NOF, underwent left hip hemiarthroplasty
under our care, and is scheduled to be
transferred to your facility today.
Postoperatively, a physiotherapist reviewed
her on the 3rd day of hospitalization and
initiated an exercise program to promote
strength and recovery. At present, she can
ambulate short distances with a walker. Her
LLE weight bearing is limited to 30% for next
six weeks.
Her husband is unable to provide care for her

in their home, which is not set up for a walker;
therefore, it would be greatly appreciated if
you could take over the management of this
patient from this point on. Please ensure
compliance with the prescribed medication
regime, attached to this letter, as well as the
recommended exercise program. Additionally,
she requires assistance with ADL. Of note, her
staples need to be removed on Day 14, and
the dressing should remain dry and intact until
then. Her medical history reveals the presence
of mild hypertension, mild hyperlipidemia,
and coronary heart disease.
Please do not hesitate to contact me in case of
any queries.
Yours truly
Diana Jones Charge Nurse
Prince Wales Hospital

09/07/2017
Ms. Nina Gill
Cardiac Rehabilitation Nurse Specialist
Cardiac Rehabilitation Clinic
41 Jones Street Adelaide
Re: Ms. Kylie Weiss; D.O.B: 21/05/1952
Dear Ms. Gill
I am writing to request continuing care and
support for Ms. Weiss who was admitted to
the hospital on 07/07/2017 for treatment of
myocardial infarction. She underwent an
emergency angioplasty under our care and is
being discharged today.
Her medical history is remarkable for
previously untreated dyslipidaemia.
Moreover, she has a family history of heart
problems in both of her siblings and her
mother. She consumes a diet that consists
almost exclusively of fast foods and is
overweight. She is a non-drinker and quit
smoking in 1994.
Postoperatively, she responded well to the
treatment and attained a good recovery. She
has been commenced on a cardiac exercise
program and advised on a low-fat diet to
reduce her weight and cholesterol levels. She
has been educated on MI and had a
reasonable understanding of the event and
subsequent diagnosis.
ensure adherence to the recommended
medication regimen, diet plan, and exercise
program. Further, please re-enforce Ms.
Weiss’s understanding about MI and
management of its risk factors for an
improved quality of life.
Enclosed you will find a copy of her current
medications. Should you have any further
inquiries, please do not hesitate to contact
me.
Yours sincerely
(Your name here)
Registered Nurse

09/07/2017
Mr. Barney Dyer
Occupational Therapist
Home Occupational Therapy Services
85 Flinders Street Adelaide
Re: Ms. Kylie Weiss; D.O.B: 21/05/1952
Dear Mr. Dyer
This letter will introduce Ms. Weiss who is
presently recovering from a Myocardial
Infarction. She was admitted to hospital on
07/07/2017 and is scheduled to be discharged
today. She requires home visits from you to
instruct her on how she can resume
independence of her daily routines.
She lives with her husband in their own house
and works as a taxi driver. Her risk factors
include being overweight and elevated
cholesterol levels.
During hospitalization, she underwent an
emergency angioplasty and was subsequently
reviewed by a physiotherapist, who initiated a
cardiac exercise program, as well as a
dietician, who advised her on a diet plan to
promote weight-loss and decrease her
cholesterol levels.
She has been advised not to drive for six
weeks and educated on MI and the lifestyle
changes required for ongoing management of
her condition.
provide instructions on returning to her
routine activities, work, and driving to ensure
a smooth transition back to normal life.
Thanking you in anticipation for agreeing to
assist in this matter. Should you have any
further inquiries, please do not hesitate to
contact me.
Yours sincerely
(Your name here)
Registered Nurse
09/07/2017
Ms. Linda Gold

Social Worker
Gold Social Services
478 Collins Street
Adelaide
Re: Ms. Kylie Weiss; DOB: 21/05/1952

Dear Ms. Gold
I am writing to request a home visit by you to

Ms. Weiss’s home to assess her eligibility for
receiving a sickness allowance or other
benefits that the Department of Human
Services provides. She was admitted to our
hospital on 07/07/2017 following a heart
attack and is scheduled to be discharged
today.
Mrs. Weiss works mixed shifts as a taxi driver
and lives with her husband, who is an aged
pensioner. Her recovery has been encouraging
so far, yet she has been advised to refrain
from driving until she has recuperated; as a
result, she will not be returning to work for
next six weeks.
Ms. Weiss is concerned about being unable to
manage their home solely on her husband’s
pension. A home visit to discuss her eligibility
for receiving assistance from the government
would be appreciated.
She has been referred to a Cardiac
Rehabilitation Nurse and an Occupational
Therapist to support her to make the
recommended lifestyle changes.
I have attached all the pertinent details for
your perusal. Please do not hesitate to contact
me in the case of any queries.
Yours sincerely
(Your name here)
Registered Nurse

29/05/2017
Ms. Carrie Andrews
Director of Nursing
52 Albert Street Brisbane 4101
Re: Mr. Anthony Nutt; 86-year-old man
Dear Ms. Andrews
I am writing to refer Mr. Nutt who has been
diagnosed with stage 3 recurrent right-sided
breast cancer. An oncology evaluation has
deemed him unsuitable for curative
treatment, and he is being transferred to your
facility today for hospice care.
Pertinent surgical history includes a right total
mastectomy 20 years ago due to right-sided
breast cancer. Postoperatively, he did not
receive any adjuvant radiation, chemotherapy,
or hormone therapy and did not pursue any
further medical follow-up. He lives with his
wife, and both of them suffer from dementia.
They have a son, Joseph, who lives 30 minutes
away.
While hospitalization, he was commenced on
hormone therapy with tamoxifen 20 mg daily
with one course of palliative radiation. A
family conference was held on 28/052017 to
elicit the goals of care, and hospice care was
found ideal for the patient given his illness,
cognitive state, his wife’s debilitating health
status, and Joseph’s hectic lifestyle.
take over the management of this patient and
provide care to maintain his dignity and
improve his quality of life. Worthy to note,
Mrs. Nutt will be transferred to your facility
the once a bed comes available for her.
Please contact with any questions.
Yours sincerely
(Your name here)

29/05/2017
Ms. Carrie Andrews
Director of Nursing
52 Albert Street Brisbane 4101
Re: Mr. Anthony Nutt; 86-year-old man
Dear Ms. Andrews
This letter will introduce Mr. Nutt who is
suffering from stage 3 recurrent right-sided
breast cancer and requires hospice care to
improve his quality of life. The doctor believes
curative treatment is no longer an option for
him.
His medical history is remarkable for right-
sided breast cancer 20 years ago which was
treated with right total mastectomy; however,
he did not pursue any medical follow-up
subsequently. He lives with his wife, and both
are suffering from dementia. Their son,
Joseph, lives 30 minutes away.
While hospitalization, the diagnosis was
confirmed with a biopsy, and he
was subsequently commenced on hormone
therapy with tamoxifen 20 mg daily with one
course of palliative radiation. The doctor
conferred with the patient’s wife and son and
advised them to proceed with hospice
enrolment given the wife’s debilitating mental
state and Joseph’s hectic lifestyle.
take over the management of this patient and
provide care to improve his quality of life and
maintain his dignity. His wife would live with
Joseph until a bed becomes available for her
in your facility.
Yours sincerely
(Your name here)
01/11/2016
Mr. Amit Kumar
Physiotherapist
Suite 5
379 Swanston Street
Melbourne
Re: Mr. Tom Clarke; DOB: 21/09/1954
Dear Mr. Kumar
I am writing to request daily home visits to
provide rehabilitative care and support for Mr.
Clarke who is recovering from a fracture of the
coronoid process of the ulna and a radial head
fracture of the left elbow.
Initially, he presented to us on 26/08/2016
with an injury on his left elbow following an
accident, and the diagnosis was confirmed
with an X-Ray. On that day, he was advised to
restrict the activity of the impacted elbow
with a sling for optimal healing and
commenced on Ibuprofen, Panadol, and
Capsule CM Plus. Additionally, he was advised
to use warm compresses to alleviate pain and
inflammation.
On his subsequent visit six weeks later, his X-
ray was reviewed which showed progress in
healing; therefore, the sling was removed, and
an exercise program was initiated to promote
healing.
The patient was seen in a follow-up today
when he complained of stiffness and limited
range of motion of the left elbow;
consequently, he was recommended a
rehabilitation program, supervised by a
physiotherapist, to restore movement and
strength to the elbow.
visit him at home and assist him with
regaining a full function of his elbow.
Yours sincerely
Ramona Decosta
Senior Nurse
Helpline Hospital

01/11/2016
Mr. Amit Kumar
Physiotherapist
Suite 5
379 Swanston Street
Melbourne
Re: Mr. Tom Clarke; DOB: 21/09/1954
Dear Mr. Kumar
I am writing to request daily home visits to
provide rehabilitative care and support for Mr.
Clarke who presented to us on 26/08/2016
with an injury on his left elbow following an
accident and was diagnosed with a
nondisplaced fracture of the coronoid process
of the ulna and a radial head fracture of the
left elbow.
On that day, he was advised to restrict the
activity of the impacted elbow with a sling for
optimal healing and commenced on
Ibuprofen, Panadol, and Capsule CM Plus.
Additionally, he was advised to use warm
compresses to alleviate pain and
inflammation.
On his subsequent visit six weeks later, his X-
ray was reviewed which showed progress in
healing; therefore, the sling was removed, and
an exercise program was initiated to promote
healing.
The patient was seen in a follow-up today
when he complained of stiffness and limited
range of motion of the left elbow;
consequently, he was recommended a
rehabilitation program, supervised by a
physiotherapist, to restore movement and
strength to the elbow.
visit him at home and assist him with
regaining a full function of his elbow.
Yours sincerely
Ramona Decosta
Senior Nurse
Helpline Hospital

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CASE NOTES 1.

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Treatment: Conservative management

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CASE NOTES: 53-56

• Blood glucose, Fluid, electrolyte,

• Initiate referrals to dietician,

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Admitted: Admitted on 22nd January, 2018

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Nursing Care Needs

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Medical Treatment: Emergency