Read the case notes and complete the writing task which follows.

Case Notes:

Mrs. Emily Ryan is a 59-year-old patient under your supervision at the hospital where you are working.

Patient Details:

• Marital Status: Widow (3 years)

• Admission Date: 4 April 2013 (New Life Hospital)
• Discharge Date: 15 June 2013
• Diagnosis: Enlarged spleen (viral infections, splenomegaly), high blood pressure

Social Background:

• Lives at ASPE House, 168 Lavender Hill London One daughter – married, works as a lecturer
• Hobbies: painting, reading Brother, J. Pereira (66), very supportive, visits regularly

Medical Background:

• 2009 – food poisoning – spent one month at the hospital (New Life)
• 2006- – High blood pressure

Medications:

• Aspirin 100mg (recommenced post-operatively), pneumococcal (pneumovax), meningococcal

and haemophilus influenzae type b (Hib) vaccines.

Nursing Management and Progress:

• Dressing on surgery site - daily

• No contact with water
• Also, follow-up FBE tests at New Life

Hospital Assessment:

• In good condition. No signs of bleeding, pain or fever. However, she still walks with support.
Blood pressure normal on discharge.

Discharge Plan:

• Monitor medications (penicillin injection as directed), avoid travelling, avoid vigorous

exercise.

Writing task:

Using the information in the case notes, write a letter to Anna D Souza, Senior Nurse at Old Age
Nursing Home, 155 Commercial Street, London, who will be responsible for Mrs. Emily Ryan’s
continued care at the nursing home.

In your answer:

• Expand the relevant notes into complete sentences

• Do not use note form
• Use letter format
Anna D Souza
Old Age Nursing Home
155 Commercial Street London
(Today’s date)

Re: Mrs. Emily Ryan, 59 years old

Dear Anna D Souza

Mrs. Emily Ryan, who was admitted into our New Life Hospital, was diagnosed with an infected spleen.
A severe viral infection (splenomegaly) was noted which required immediate attention.

The patient is a widower and has one daughter who is married and works as a lecturer, the one who
brought her to the hospital. She also has a brother who visits regularly. Apart from a problem related
to food poisoning which occurred once and high blood pressure (the patient still has high BP), Mrs.
Ryan has no previous medical history.

The patient was prescribed aspirin 100 mg (post-operatively) and advised to continue the use of
pneumococcal (pneumovax), meningococcal and haemophilus influenzae type b (Hib) vaccines. There
will strictly be no contact with water and dressing on the surgery site is requested to be done daily.
Follow-up FBE tests are recommended as well.

It is suggested that the patient should not perform vigorous exercises and that the patient should
avoid travelling until they have made a full recovery. Please, contact me with any queries.

Yours sincerely
Charge Nurse