OET Writing Case Note (Nurses)

WRITING SUB-TEST: NURSING 

TIME ALLOWED:       READING TIME: 5 MINUTES

                                         WRITING TIME: 40 MINUTES


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

NOTES: 

You are an intensive care nursing instructor at Methodist Hospital, Chicago.

Today's date: 27 Jan 20200


PATIENT DETAILS

Name: Mrs. Adriana Hakim

Age: 73 years

DOA: 25 Jan 2022

Marital Status: Widow

Diagnosis: Chronic renal failure and ARDS

Social History

* African American

* Retired Chef

* Husband died 15 years ago

* Lives alone in a rented house.

* One daughter, Maureen-married and lives in Spain

Past Medical History:

T2DM - 20 years

HTN - 15 years

Obesity (Sedentary lifestyle) BMI 30 kg/m2

Rheumatoid arthritis - 5 years

CRF - 1 year  9dialysis -twice a week)


Past Surgical History

.Cataract (2021)

.Rt big toe amputation 2018)

Family History:

* T2DM  - both parents

* HTN both parents

* Rheumatiod arthritis - sister.


Regular Medications:

* Methotrexate 2.5 mg daily

* Humulin R sliding scale

* Atelol 25 mg HS

Atorvastatin 10 mg HS

Current Medication:

* Esomeprazole 40 mg OD ( before breakfast)

* Paracetamol 1000mg PRN

* Fefol vit OD

* Calcite 600 OD - OTC

 

Recent Nursing Notes:

21 Jan 2022

* Arrived at community health clinic

* C/O difficulty in breathing and mild back pain

* Wt: 90 Kgs, Ht: 157, BP145/88, HR  76 b/min.  O2 Sat. 95%

* HB: 10 g/dl

* Prescribed: fefol vit tab OD & Calcite 600 mg OD

26 Jan 2022

* Arrived at emergency care

* Accompanied with neighbor

* C/O severe SOB, back pain, facial and limb swelling. coma.

* GCS 13/15, CBR

* Intubated and kept on a mechanical ventilator

* Shifted to ICU

26 Jan 2022

* Pt developed loose, watery diarrhea

* Diaper in place

* First degree bedsore observed (skin peel off) - sacral area.

* Comfeel applied

* Skin turger: Loose

* Positioning every shift

* Back care every shift

27 Jan 2022

* Sacral bedsore progress to second degree

* One more first degree bedsore on th rt buttock region

* No positioning dome for the last 15 hours

* Loose watery diarrhea continues

* Last back care done 8 hours ago

Plan:

* Refer to bedsore nurse

* Avoid diaper use (remove wet/unclean sheets immediately)

* Perform back care q2h

* Keep the pt in lateral position

* Keep the affected region clean and dry

* Use air mattress

* Avoid massaging bony prominences.


                                          WRITING TASK

Using the information given in the case notes, write a letter to Ms. Seema Iqbal, Senior Wound specialist and Bedsore Champion , Methodist Hospital, Chicago, informing her about the patient's condition and requesting her to visit the patient as soon as possible, Also, detail out the plan of care required to managed patient's pressure ulcers.


* DO NOT use note forms

* Expand the case notes where relevant into full sentence

* Use formal letter format

  The main par of the letter should be approximately 180 - 200 words long








 


                _______ The End______________










































































 











 

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