OET Writing (NURSES) - Urgent referral

 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.

Assume that today's date is 30 August 2019.

 You are a nurse conducting a Nurse Home Visit as a part of routine follow-up care after this patient's recent hospital discharge. 

PATIENT DETAILS

Name:          Ms Patricia Styles

BOB:           27 Apr 1957 (Age 62)

Address:     57 Market Drive, Newton

Social 

background:         Retired primary school teacher

                             Lives on her own

                             Husband died 3 yrs ago (lung cancer); no children

Medical 

history:                HT (hypertension) diagnosed 2011 - mild 145/95; moderate 168/105 in                                2013, commenced quinapril. Regular monitoring. Currently well                                              managed at 140/90.

                             Diabetes mellitus (DM) Type 2. Diagnosed 2013 - pt counselled re                                         diet/lifestyle, incl. weight loss

                            2014 - commenced oral hypoglycaemics. Well managed generally

                            Depression - diagnosed June 2016. Triggered by death of husband. 

                            Regular counselling since 2016 to control mood swings and support DM                                management

Family

history:              Mother HT, DM

Lifestyle:            Smoking/Alcohol: Non-smoker, 1-2 glasses wine/wk

                           Exercise: walks dog 20 min/day

                          Diet: Ongoing counselling re DM management to maintain balanced diet.

Medications:     Quinapril, oral 40mg/2 x day

                           Metformin, oral 500mg/2xday

                           Gliclazide, oral, 30 mg daily

Green Valley Hospital Treatment Record:

23 Aug 2010 :   Pt visiting sister for weekend, sister lives 3 hrs away from Newtown in                                    Green Valley

                         Pt admitted to Green Valley Hospital late evening with fever, sharp &                                     pleuritic chest pain (worse on breathing), general weakness & malaise,                                   tachycardia (rapid heartbeat).

24 Aug 2019:   Vital signs: RR: 29, BP: 170/106; HR: 98, T 39.3C

                         FBE: ESR, CRP, WCC, 

                        Throat swab: viral influenza - type B

                        CXR - normal

                        Echocardiogram - pericarditis 

Management:  IV saline, Ibuprofen 600mg everyday 8hrs

Assessment:    Viral influenza type B , plus pericarditis.

25 Aug 2019:  Pt discharged and advised on self-care at home .

                        Niece drove pt home  & agreed to stay overnights 

                       Follow-up Nurse Home Visit arranged for 30 Aug 2019

Nurse Home Visit - 30 Aug 2018: 

Observations:      Pt unhappy,  Reports feeling chest pain (relived by sitting up) SOB,                                        fatigue.                  

                              Frustrated with progress of recovery

                              Medication adherence - reports compliance & glucose and regular blood                                glucose monitoring 

                              Vital signs: loe-grade fever, T: 38.1C, Elevated RR 28 & HR 115, BP:                                   140/90

                             Niece no longer staying overnight - work commitments

Assessment:        Pt unwell. Nil improvement.

                           ? relapse/complications of pericarditis

Plan:                   Organise urgent hospital transfer to Newtown Hospital 

                          Write referral to emergency department, include relevant * medications, 

                          * pt history, test results/observations. 


WRITING TASK

Using the information in the case notes, write a letter  of referral to the emergency department consultant on duty, outlining the case and requesting urgent assessment for pericarditis. Address the letter to emergency department consultant on duty, Newtown Hospital 100 Main Street, New town..

In your letter: 

* Expand the relevant case notes into complete sentences

* Do not use note forms

* Use correct letter format

The body of the letter should be approximately 180-200 words.




____________ The End________








































































































































































































































 

















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