Today’s date: 05/04/12 You are Annie Smith, Cardiac Nurse, at the Prince Charles

Hospital, Brisbane. Your patient is Mr.Yanlin Ma who underwent emergency cardio-

thoracic surgery on the 31st March 2012. Patient details
• DOB: 12th March 1980
• Nationality: Chinese
• Marital Status: Single, no family in Australia
• International student on scholarship for Masters in Information Technology

Medical & Surgical History

• No known allergies
• No previous surgery
• Reports high blood pressure since late 2010
• Medications: Panadine Forte for headaches
• Alcohol use: does not drink
• Smokes 5-6 cigarettes per day
• Weight 105kg, Height 182cm
• Family history: Father died of aortic aneurysm at age 44

31/03/12
• Presented to Royal Brisbane and Women’s Hospital with severe chest and back pain
• CT scan showed severely dilated ascending aorta and type-A dissection
• Transferred to Prince Charles Hospital
• In acute pulmonary oedema on arrival
• Echocardiogram performed, showing aortic valve incompetence
• Open-chest surgery for repair of aortic aneurysm and aortic root replacement with
mechanical valve

Post-operation
• Hypertensive initially post-op
• Blood pressure stablised by day 3
• Satisfactory post-operative recovery
• Reviewed by physiotherapist – exercise program provided
• Started on Warfarin therapy
• Cardiac outpatient's appointment at 3 and 6 months post-op
• To be discharged 09/04/12

Plan
• Routine wound care
• Patient education on Warfarin therapy
• Monitor BP. To be maintained at 120/80 or below

Social

 Mother has come to Australia urgently from China. First time in Australia, no
English
 His lease on rental accommodation has recently expired
 He will not complete this semester’s university assessment on time
 His visa also expires at end of semester
 Concerned about being able to lose weight and stop smoking

Writing Task

Write a referral letter to Ms Susan Williams, the hospital social worker, requesting her to
see your patient before discharge to assist with: accommodation; letters for university
and department of immigration; referral to programs for smoking cessation and weight
loss/exercise.
• Do not use note form in the letter
• Expand on the relevant case notes into complete sentences
• The body of the letter should be approximately 200 words long
• Use correct letter format