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Writing Test 3
Writing Test
Time allowed:
Writing : 40 Minutes
Read the case notes below and complete the writing task which follows.
Hospital Royal Perth Hospital
Patient Details Alfred Billy

52 Years old
Marital status: married
Wife to be contacted if there is any sort of emergency:
Maria Jennifer, Arillon City Arcade 207 Murray Street Perth
Admission Date 21/03/2010
Discharge Date 5/05/2010
Diagnosis Skin cancer – BCC (Basal Cell Carncinoma) (neck)

Nodular basal-cell carcinoma
Past Medical No prior hospitalization, no history
History Medications
Social Truck Driver
History/Supports Lives with her wife

Habit of consuming liquor for th past 30 years
Cigarette Smoker
Skin dark
Religion: Protestant
Medical Progress Skin biopsy is taken for pathological study

CCB - removal of
Pain reliever panadein forte 500mg
Nursing No complications noted
Management Perfectly well at the time of discharge

No complain of any pain
Discharge Plan Daily obs
Medicine to be taken for one more week
Writing Task
You are the charge nurse on the hospital ward where Mr. Alfred Billy has recently had his
operation. Using the information provided in the case notes, write a referral letter to the
Community Nurse Head at Care Well Hospital, Birmingham, who will be attending to Mr.
Alfred Billy, following his discharge.
In your answer:
 Expand the relevant case notes into complete sentences.

 Do not use note form.
 The body of the letter should be approximately 200 words.
 Use correct letter format.
OET Preparation: Writing
Writing Test: Nurses
Time allowed: 40 minutes
Red the case notes below and compete the writing task which follows.
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.
Discharge summary:
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

• counseled re nutrition and pregnancy
• counseled re HIV/AIDS and STDs risk
• discussed possibility of rehabilitation clinic for ‘driving out’
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 8 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:
• 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 8an, Registered Nurse, Community Health
Centre, St Kilda.
Sample Writing Task: Nurse

Read the case notes below and complete the writing task which follows:
You are Sonya Matthews, a qualified nursing sister working with the Blue
Nursing Home Care Agency. Bob Dawson is a patient in your care. Read
the case notes below and complete the writing task which follows.
Name: Bob Dawson

Address: 141 Montague, West End 4101
Phone: (07) 3442 1958
Date of Birth: 25 September 1924
Social Background
Married – wife Elizabeth aged 83. Lives in own home – Both receive age
pensions
Bob is World War11 Veteran with Gold Health Card entitlement
Medical History:
Cerebrovascular accident (CVA) 4 years ago
Rehabilitation generally successful - Mentally alert, slight speech
impairment, - residual weakness left side - walks with limp – balance
slightly impaired.
18 /5/08
Had fall descending stairs. Badly grazed left knee. GP has requested daily
visits by Blue Nursing Home Care to dress wound and assist with showering.
19.5.08
Grazed knee redressed – no sign of infection
Bob managing to get around the house slowly with aid of his wife.
Reports that apart from “usual aches and pains” he is doing well.
23.5.08
Knee healing well.
Suggested use of a walker or walking stick to assist with mobility.
Bob said he had a walking stick but it was useless. Wife says he had never
learned to use it properly. She asked if I would contact their local
physiotherapist to see if Bob could receive a home visit to assess further
assistance to improve his mobility.
WRITING TASK
Using the information in the case notes, write a letter to Ms Marcia
Devonport, West End Physiotherapy Centre, 62 Vulture Street, West End,
Brisbane 4101 on behalf of Mrs Elizabeth Dawson requesting a home visit to
provide advice and assistance with improving her husband’s mobility.
Do not use note form in the letter. Expand on the relevant case notes to
explain his background and medical history and the assistance requested.
The letter should be 15-20 lines long. No more than the first 25 lines will be
assessed.

Name: Bob Dawson

Phone: (07) 3442 1958
Social Background
pensions
Medical History:
slightly impaired.
18 /5/08
19.5.08
23.5.08
Knee healing well.
WRITING TASK
assessed.
CASE STUDY No.1 - Mavis Brampton [5 mins reading / 40 mins writing]
This patient has been in your care and is now going home from the Northern Community
Hospital, Moreland, 3051.
Patient: MAVIS BRAMPTON - 72 years old

Admitted: 10 January 2011 To be discharged: 15 January 2011
Diagnosis: Pleurisy
BACKGROUND:
 Mrs Brampton has been widowed 25 years. Has been an active member of the
community all her life. Is the current President of PROBUS in her area. She with her
husband ran the Sydney Road Newsagency until his death at which time she retired.
Attends the local Community Centre three times a week to play Bingo. Has been a
smoker all her life (since 18 years of age). Current smoking 10 a day.
NURSING NOTES:
• 10 Jan 2011 Overweight: BMI 29 Had CXR; IV Amoxycillin with supplementary O2
• Advised to give up smoking.
• BP 170/90 Pulse 92 Slightly raised temperature: 39oC Breathless
12 Jan 2011 On low-dairy diet Advised about Nicotine patches.
• Productive cough – sputum culture done Pravastatin 20mg/day and Celecoxib
100mg/day
13 Jan 2011
• Deep breathing exercises started. Is keeping to a non-smoking regime.
• Using Nicotine patches and Zyban (150mg b.i.d).
• To be discharged 15 Jan 2011.
DISCHARGE PLAN:
• Support Mrs Brampton - needs monitoring for medication compliance
• Needs help with nutritious meals (Meals on Wheels) and house keeping (Council
Home Help) - Assistance with shopping
• Monitor her quit-smoking plans - watch for side effects from Zyban such as dry
mouth and difficulty in sleeping. If side effects occur Zyban should be stopped.
Zyban to be withdrawn after 2 months. Nicotine patches to continue until
smoking addiction is under control.
WRITING TASK:
Write a letter of referral to Brunswick Family Care Clinic, 44 Decarle Street, Brunswick,
Vic 3056 requesting monitoring and ongoing care be arranged for Mrs Brampton.
Community Nurse to make sure Mrs Brampton continues her cessation of smoking –
with the help of Nicotine patches and Zyban. Zyban tablets to cease as soon as side
effects occur (if any). Both Zyban and Nicotine to cease as soon as craving for cigarettes
has stopped. Letter should be 180 to 200 words long / only the first 25 lines will be
considered.
CASE STUDY No.1 - Beverley Williams Born 1943
PATIENT
This patient has been in your care for the past 10 years. During the past 8 years Mrs
Williams has developed diabetes. It is not well controlled. You are now referring
her on to a Public Health Nurse for a health education program.
HISTORY
� Type II Non Insulin Dependent Diabetes – onset 8 years ago
� Prescribed tablets soon after diagnosis
� No problems with sugars or infections
� Has monitored urine with sticks at home
� Not always well controlled
� Does not care about diet regime
� High BP for past 5 years – on medication
� Overweight for past 30 years (BMI 32)
� Vision OK
� Has worn spectacles for past 20 years
� Grandmother had Diabetes; died of gangrene of the foot
� Husband is also Diabetic
DIABETIC HABITS
� No special diet
� Tries not to have sugar
� Buys diabetic cordial
� Tastes food while preparing meals in kitchen
� Eats cream cakes at afternoon tea time
� Loves fruit
� Unaware of consequences of careless diet
� Has trouble losing weight
� Very little exercise – walks around the neighbourhood occasionally
� Likes a glass of wine with evening meal
RELATIONSHIPS
� Has four children – all adults – all married
� Gets on well with husband
� Likes visiting her daughter in the country
� Has active social life – visit friends regularly
TREATMENT PLAN
� Monitor urine – monitor blood sugar levels with glucometer
� Needs to be educated re Diabetes and importance of special diet
� Needs to attend formal diabetic education program (daytime classes at Hospital)
� Increase Daonil from 15 to 20mg per day
� Needs vision checked every two to three months
� Needs to lose weight – has increased 3.5kg in last 6 months
� Suggest a suitable exercise program ? Swimming
WRITING TASK
Using the information in the case notes, write a letter of referral to: Ms Michella
Mansoura, Public Health Nurse, 125 Canterbury Road, Ringwood, Victoria 3134
Australia. DO NOT use note form – use complete sentences. Expand the relevant
notes in the treatment plan requesting that Ms Mansoura take over the management
of this patient. Letter should be no more than 25 lines long.
Sample Writing Task 2: Dylan Charles
Read the case notes below and complete the writing task that follows.
Time allowed : 40 minutes
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 Histor
• 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 letter expand the relevant case notes into complete sentences
• Do not use note form
• The body of your letter should be approximately 180~200 words
• Use correct letter format.
Mr Gerald Baker is a 79-year-old patient on the ward of a hospital in which you are Charge Nurse.
Patient Details:
Marital Status: Widower (8 years)
Admission Date: 3 September 2010 (City Hospital)
Discharge Date: 7 September 2010
Diagnosis: Left Total Hip Replacement (THR)
Ongoing high blood pressure
Social Background: Lives at Greywalls Nursing Home (GNH) (4 years)
No children
Employed as a radio engineer until retirement aged 65
Now aged-pensioner
Hobbies: chess, ham radio operator
Sister, Dawn Mason (66), visits regularly; v supportive
– plays chess with Mr Baker on her visits
No signs of dementia observed
Medical Background: 2008 – Osteoarthritis requiring total hip replacement surgery
1989 – Hypertension (ongoing management)
1985 – Colles fracture, ORIF

Medications: Aspirin 100mg mane (recommenced post-operatively)
Ramipril 5mg mane
Panadeine Forte (co-codamol) 2 qid prn
Nursing Management and Progress:
daily dressings surgery incision site
Range of motion, stretching and strengthening exercises
Occupational therapy
Staples to be removed in two wks (21/9)
Also, follow-up FBE and UEC tests at City Hospital Clinic
Assessment: Good mobility post-operation
Weight-bearing with use of wheelie-walker; walks length of ward without difficulty
Post-operative disoriention re time and place during recovery, possibly relating to

anaesthetic – continued observation recommended
Dropped Hb post-operatively (to 72) requiring transfusion of 3 units packed red

blood cells; Hb stable (112) on discharge – ongoing monitoring required for anaemia
Discharge Plan: Monitor medications (Panadeine Forte)
Preserve skin integrity
Continue exercise program
Equipment required: wheelie-walker, wedge pillow, toilet raiser. Hospital to provide

walker and pillow. Hospital social worker organised 2-wk hire of raiser from local
medical supplier.
Writing task:
Using the information in the case notes, write a letter to Ms Samantha Bruin, Senior Nurse at Greywalls Nursing Home,
27 Station Road, Greywalls, who will be responsible for Mr Baker’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
The body of the letter should be approximately 180-200 words.
Practice writing sub-test No.008 for nursing
Read the case notes and complete the writing task which follows
Notes
Harry Kovacs is a 5 year old boy who is the son of one of your newly referred patients in the
community mental health centre where you are a mental health case manager.
Date of birth: 15 April 2006
Place of birth: Sydney Children’s Hospital, Sydney
School year: Kindergarten
Religion & ethnicity: Catholic & both parents Australian born Hungarian
Mother’s name: Elizabeth Kovacs
Mother’s community admission date: 16 May 2011
Diagnosis: Mother – Major depression with psychotic features
Son – ? Early onset separation anxiety disorder
Family/Psychosocial: * Elizabeth suffered PND – depressed since
*She sometimes hears voices calling her and sees ‘men’

running around her house – nil serious psychosis in
functional terms.
* Recently 1st psych admission for 6/52after high

lethality DSH attempt.
*Harry’s psychological status ok until DSH and

hospitalisation; after this +++ signs of separation
anxiety
*Father is self employed and works long hours 7/7. Rarely

sees Harry & dismissive of Harry’s emotional states, ‘He’s
like a bloody girl now!’ he told us.
*Harry loves soccer and playing with his dog, ‘Rusty’.

Medical History
Eczema
Serous otitis media – required grommets at 18 mths
Hearing NAD now.
Medication Nil meds
Case management care and progress:
* Elizabeth new to our area (from Parramatta) & referred to

us post D/C from Bankstown MH inpatient unit 2/52 ago
*We will provide her with long term MH case management.
*Harry now 1) cries and panics whenever Mum leaves his
sight 2) Socially withdrawn & refusing to attend
kindergarten 3) ↑ insomnia & nightmares 4) preoccupied
re Mum’s daily activities & that she might leave him again.
* This is greatly ↑pressure on Elizabeth when her MH
is already fragile.
* Father, John, uninterested in meeting in person or
discussing problems in detail.
*Harry attended initial assessment with Elizabeth and
separation anxiety behaviour very obvious
Referral plan: * Referral to early childhood mental health team for

assessment and management of Harry’s ? early onset
separation anxiety disorder.
*Request joint meeting with case manager and Elizabeth.
You are the Case Manager caring for Harry Kovac’s depressed mother but due to his psychological
issues need to write a referral for him to John Dyer, Clinical Psychologist on the Bankstown early
childhood mental health team at Bankstown Hospital.
In your answer:
 Expand the relevant notes into complete sentences

 Do not use note form
 Use letter format

Today's date: 9/7/08
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 4 mg 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 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 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 (07) 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
Using the information in the case notes, write 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.
Do not use note form in the letter; expand the relevant case notes into full sentences. The
letter should be 15-20 lines long. No more than the first 25 lines will be assessed.
Mr Lionel Ramamurthy, a 63-year-old, is a patient in the medical ward of which you are Charge Nurse.
Hospital: Newtown Public Hospital, 41 Main Street, Newtown
Patient details
Name: Lionel Ramamurthy (Mr)
Marital status: Widowed – spouse dec. 6 mths
Residence: Community Retirement Home, Newtown
Next of kin: Jake, engineer (37, married, 3 children <10)

Sean, teacher (30, married, working overseas, 1 infant)
Admission date: 04 February 2014
Discharge date: 11 February 2014
Diagnosis: Pneumonia
Past medical history: Osteoarthritis (mainly fingers) – Voltaren

Eyesight due to cataracts removed 16 mths ago – needs check-up
Social background: Retired school teacher (history, maths). Financially independent. Lonely since wife
died. Weight loss – associated with poor diet.
Medical background: Admitted with pneumonia – acute shortness of breath (SOB), inspiratory and
expiratory wheezing, persistent cough ( chest & abdominal pain), fever, rigors,
sleeplessness, generalised ache.
On admission – mobilising with pick-up frame, assist with ADLs
(e.g., showering, dressing, etc.), very weak, ambulating only short distances with
increasing shortness of breath on exertion (SOBOE).
TURN OVER 2
Medical progress: Afebrile.
Inflammatory markers back to normal.
Slow but independent walk & shower/toilet.
Dry cough, some chest & abdom. pain.
Weight gain post r/v by dietitian.
Nursing management: Encourage oral fluids, proper nutrition.

Ambulant as per physio r/v.
Encourage chest physio (deep breathing & coughing exercises).
Sitting preferred to lying down to ensure postural drainage.
Assessment: Good progress overall
Discharge plan: Paracetamol if necessary for chest/abdom. pain.

Keep warm.
Good nutrition – fluids, eggs, fruit, veg (needs help monitoring diet).
Writing Task:
Using the information given in the case notes, write a discharge letter to Ms Georgine Ponsford, Resident
Community Nurse at the Community Retirement Home, 103 Light Street, Newtown. This letter will accompany
Mr Ramamurthy back to the retirement home upon his discharge tomorrow.
In your answer:
• Expand the relevant notes into complete sentences
• Use letter format
The body of the letter should be approximately 180–200 words.
3
Patient Details
Patient: Maria Joseph is a 39 years old woman who has been a patient at a hosptical you
are working in as a head nurse. Apart from usual childhood illness such as chicken pox,
she had been healthy.
10 / 5 2011
Subjective: Frontal headache for 6 hrs. Mild assoc, suffering from nausea, no vomiting,
patient with blurred vision but not aura. No other symptoms noticed. She has no family
history of migraine.
 Objective P96, BP 130/ 70. Normal Cervical Spine Movement, examination

normal.
 Assessment Probably due to excess tension or personal dilemma
 Plan Advised to take rest. Given analgesia (paracetamol (500q4h))
14/5 /2011
Subjective Complained of continuous headaches (left sided and frontal), blurred vision,
throbbing headache (left sided). Vomited 5 times during last three hours Complaining of
slight paraesthesia.
 Objective Distressed, P 103, BP 150/90, Normal peripheral nervous

system
 Assessment Severe Migraine Possibility
 Plan: Stat- Pethidine 100 mg, intramuscular injection Maxolon 10 mg

15 / 5 / 2011
Home Visit
Subjective Fell down at home due to severe left sided headache, started some 5 hrs after
reaching home. Injured her right arm, bruises on left leg. slurred speech, half unconscious.
Objective P 100, BP 150/90, extension 4/5 power, left leg knee flexion 4/5
Assessment Probable intracranial pathology, space occupying lesions.
Plan Urgent assessment in Emer. Dept.
Using the information given above write a letter to the neurologist, who will attend the
patient in the emergency department.
In your answer:
Expand the information given in complete sentences

Do not use note forms
Use only letter format.

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
Hospital: Lyell McEwin Hospital
Patient Details: Name: Martin Wilson

Age: 62
Admission Date: 13 October 2009
Discharge Date: 24 October 2009
Diagnosis: Attempted suicide – overdose of Mogodol
Past Medical History: Heavy smoker (40 cigarettes/day)

Bronchitis (multiple episodes)
Underweight – 66kg, BMI 18
Psoriasis
Social History: Retired 2 years ago (bookkeeper with Holden Car Company)
Lives with wife, Joan, and adult son in housing trust maisonette in
Elizabeth.
Wife works at Coles, son unemployed
2 married daughters and 5 grandchildren.
Regular social drinker
Depression related to gambling addiction
Began gambling 2 years ago
Has lost a lot of money including superannuation funds and is
in debt.
Wife and family previously unaware of addiction – very angry but
also upset about suicide attempt
Patient remorseful and ashamed
Wants to overcome addiction
Used to be a keen lawn bowls player
Has lost friends as result of gambling
Nursing Management: Weak and depressed. Anti-depressants prescribed – Lovan 200g
BP 130/95
Diagnosed with Type II diabetes.
Diabetes education regarding diet and oral medications
Wheelchair use from 20/10
Psoriasis on Torso and scalp – Diprosone OV cream 2x/day,
Ionil T Shampoo
Poor appetite
Physically unfit
Discharge Plan: Encouragement to maintain anti-depressant medication routine as

the SSRI is established. Mrs Wilson will help with supervision
Monthly follow-up appointments with psychologist Dr Brian
Murphy, Lyall McEwen Hospital
Social worker appointment to be made for gambling addiction
therapy
Strong encouragement and assistance to join Gambling Addiction
Action Group, Elizabeth Community Centre
Contact with Quitline needs to be encouraged
Wheel chair required for another week. Frame advised after this
Maintain psoriasis treatment
Maintenance of low GI diet for diabetes – involvement of wife
necessary
Encouragement in social sporting activities eg lawn bowls?
Writing Task
Using the information in the notes, write a letter to the social worker, Ms Jennifer Adams, at the
Elizabeth Community Health Centre, 125 Munno Parra Avenue, Elizabeth, 5098 requesting follow-
up care. Stress that Mr Wilson’s case needs urgent attention.
In your answer:
 expand the relevant case notes into complete sentences

 do not use note form
 use letter format
E:\Weebly\2013\Sarah\Mr Wilson - sample question.doc

Case Notes:
Mr Benjamin is a 63 – year-old patient in Care Well Hospital where you are acting as a
Charge Nurse.
Patient Details
Marital Status Widower (8 years)
Admission Date 5 September 2009 (Care Well Hospital)
Discharge Date 9 September 2009
Diagnosis THR – Total Hip Replacement

Higher BP
Social Background Lives in Abrina Nursing Home

19-21 Victoria Street ASHFIELD NSW 2131
Had been there for 2 years before coming to
Care Well (2 months ago)
Has no children
Worked in a bank as an accountant before quiting at age 60
No Pensioner
Hobbies: reading, writing, chess
Brother, Peterson, pay visits daily
No severe signs of dementia are observed yet
Medical Background 2005 – Osteoarthritis requiring total hip replacement surgery
2003 – Blood Pressure (mangaement ongoing)

Medications Aspirin (100mg)
Ramipril 5mg
Nursing Management Dressing Daily

and Progress Recommend stretching exercises
Follow up FBE and UEC tests
Assessment Good Condition – post operation

Walks with aid in the beginning but now walks
perfectly with wheelie-walker
Appeared disoriented during post operative
recovery - possibly anesthetic
Hb dropped (71) post operatively, transfused
three units of packed RBCs
Hb normal on discharge (112)
Discharge plan Pain reliever given Panadeine Forte (6tablets / day)

Exercise recommended
Equipment required: wheelie-walker, wedge pillow, toilet raiser.
Hospital is providing Wheelie-walker and wedge pillow.
With help from local medical supplier, raiser hired for 2 weeks.
Writing Task
Using the information in the case notes, write a letter to Ms Susanna Bates, Senior Nurse
at Abrina Nursing Home 19-21 Victoria Street ASHFIELD NSW 2131, who will be
responsible for Benjamin's continued care at the Nursing Home.
In your answer:

Notes
Mr Dallas Walters is a patient on a renal ward where you are the charge nurse
Age: 51
Marital status: Married with 2 adult children
Religion & cultural background: Uniting Church & aboriginal background
Admission Date: 16th June 2011, Charles Gardiner Hospital
Discharge Date: 22nd June 2011
Diagnosis: Insertion of continuous ambulatory peritoneal dialysis

(CAPD) catheter for CRF
Family/Psychosocial: *On Disability Support Pension (DSP) for schizophrenia
*Mental status relatively stable with mild chronic delusions -
‘Aliens are spying on me 24/7’.
*Supportive wife = his carer; has mild intellectual disability
* Live in demountable home in Bunbury Caravan Park
*Pt loves fishing and AFL.
Medical History *Mild CRF for 4 years; recently worsened
*Type 2 diabetes. Stable/compliant with oral meds
*Removal cataract left eye & insertion of intraocular lens
*Quit smoking and drinking 4 years ago – previously heavy
for +++ years.

Medications To be forwarded by medical officer
Management and Progress during Hospitalisation:
*Uneventful procedure; catheter inserted successfully

*Prolonged admission as pt and wife slow to learn
management of CAPD
*Hyperkalaemic & needed cardiac monitoring for 2/7
But K+ = 4.0 on D/C (N = 3.5-4.8)
*S/B mental health liaison & their Reg. happy that nil acute
changes with pt’s psychosis
Discharge Plan: *+++ CAPD /CRF education for pt and wife

*Monitor for catheter infection or signs of
peritonitis
*Important to educate on minimising K+ in diet.
*Observe for signs of ↑psychosis & refer prn
*If necessary, get community aboriginal health worker
to reinforce CAPD/CRF education
Writing task
Using information provided in the case notes, write a letter of referral to the renal Clinical Nurse
Specialist (CNS) at the Bunbury Community Health Centre for ongoing community care of the patient.
In your answer:


Time Allowed
Reading time = 5 minutes
Writing time = 40 minutes
Notes
Mr Ming Zhang is a 24 year old male patient on the mental health ward where you are a charge
nurse.
Name: Ming Zhang
Age: 24
Cultural background: From China. Speaks ↓English. Needs interpreter.
Admission Date: 5th April 2011 Macquarie Hospital Rosella Ward
Discharge Date: 26th April 2011
Diagnosis: Major depression and deliberate self poisoning (DSP)
Social background: - Came to Australia as a labourer 5 years ago
-Permanent resident now
-Wife had affair and divorced pt 1yr ago.
-Depressed and unemployed since
-Lives in own house with NESB mother out from China.
-Mother doesn’t like pt taking psych meds due to her
Chinese medicine beliefs
-Pt hobbies are fishing & online trading
Psychiatric & Medical background: - Nil Hx of depression pre divorce
- 1st presented 1 yr ago with 1st episode DSP and major

depression
- Attended Chinese psychologist sporadically this year
- Current presentation is 2nd DSP and mental health
admission.
- Medical history of gout, previous hepatitis A, # L tibia, #
R humerus, # L clavicle (all separate occasions and
resolved; work related)
Medications: - Mirtazipine 30 mg nocte

Nursing Management and Progress: -Frequently S/B Chinese speaking transcultural mental
health worker and received 1:1 CBT counselling.
-++ insomnia & ↓mood
-Mirtazipine ↑from 15mg to 30mg 12/4/11
-Mother educated via interpreter re importance of

Antidepressant (AD) meds
-Nil suicidal ideation (SI) at present, please monitor closely

for SI in community
Assessment: Mood low but improved
Low risk of self harm with close follow up and support
Good response to CBT
Discharge Plan: - For case management via community mental health team
-Ideally assign pt to Chinese speaking clinician or use

interpreter service
-Continue CBT
-Observe response to ↑ AD Rx, monitor for side effects
-Encourage ↑ physical exercise & job hunting
-Avoid prescribing benzo meds as pt uses these to DSP
Writing task
You are the Charge Nurse on the mental health ward where Mr Ming Zhang will be discharged from
and need to write a nursing referral letter to the local community mental health team. Address the
letter to Team Leader, Ryde Community Mental Health Team.
In your answer:


Writing Sub-Test: Nursing
Time allowed: Reading time: 5 minutes
Writing time: 40 minutes
Notes
Hospital: The Royal Adelaide Hospital

Patient Details: Name: Mr Robert
DOB: 02/06/52
Marital Status: Married
Next to kin: Wife
Admission Date: 1 October 2011
Discharge Date: 26 November 2011
Reason for admission: Chronic cough, hoarseness, difficulty
breathing upon exertion
Diagnosis: Squamous Cell Carcinoma of left lung
confirmed by CT scan
Past Medical History: HT diagnosed June 2008
Frequent episodes of bronchitis
Heavy smoker-40 years (1-1 ½ pack/day)
Non- drinker
Social History: Lawyer
Supportive wife
2 married daughters in regular contact. One
is 6 months pregnant
Medical Progress: Resection of the lung
Chemotherapy and radiotherapy
Ineffective treatment: metastases in liver
and spine
Cancer in terminal stages-Mr Jones wishes
to return home
Nursing Management: Fluid management
Oxygen therapy
Patient comfortable
Pain management: Morphine sulfate 40mg 4 hourly / 20mg
dose as needed.
Discharge Plan: Monitor pain status
Manage symptoms
Check need for assistance with mobility /
bathing
Daughters want father to stay in hospital for
further treatment
- provide family with emotional support
Writing Task
Using the information given in the case notes, write a letter to Marry
Watson, Palliative Care Manager, Royal District Nursing Service (RDNS)
about the patient.
In your answer:
• expand the relevant case notes into complete sentences
• do not use note form
• use letter format
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
OCCUPATIONAL ENGLISH TEST
Mobility & activities of daily living (ADLs):
Day 2 Sitting out of bed (SOOB) short periods, full assistance
WRITING SUB-TEST: NURSING
Day 3 Mobilising with pick-up frame (PUF) & 2-person assist
Day 4 Uneventful
TIME ALLOWED: READING TIME: 5 MINUTES Day 5 Mobilising short distances with PUF & 1-person assist
WRITING TIME: 40 MINUTES Abduction pillow when resting in bed (RIB)
Anti-embolic stockings in situ for 14 days
Read the case notes below and complete the writing task which follows. ADLs – full assistance
Day 6 Uneventful day
Preparing for discharge
Notes:
Discharge plan:
Patient: Mrs Beryl Casey (DOB: 21/11/1941) is a 72-year-old woman who is being
Day 7 (1100hrs) Discharge to the Rehabilitation Centre
discharged from hospital to a rehabilitation centre.
Discharge medications – Ramipril 5mg daily, paracetamol 1g qid prn
Marital status: Widowed (recently) Family to be notified of transfer
Hospital transport arranged for 1100hrs
Family: 2 children – son lives locally & daughter interstate.
Day 8 Repeat check of hemoglobin (Hb) levels
Social: Lives alone in 2-bedroom house with stairs to entrance. Son (married, 2 children – Monitor BP b.d., for 3/7, due to adjustment in anti-hypertensive meds
6 & 8) lives 20 minutes away – visits twice a week. Assess for rehab therapy (inpatient & on return home)
Enjoys gardening.
Day 10 Removal of remaining staples, wound can remain exposed afterwards
Medications: Anti-hypertensive (Ramipril) 10mg
Admission date: 4/02/14 at 1200hrs

Fainted getting out of bed & fell to the oor. Found by son 2 hours later.
Diagnosis: X-ray – fractured left neck of femur (# L NOF) post fall

Writing Task:
Treatment: Left hemiarthroplasty (Austin Moore hip replacement); general anaesthesia
Incision closed with staples & 2x Exudrain Using the information given in the case notes, write a discharge letter to the Nursing Unit Manager, The
Rehabilitation Centre, Waterford.
Post operation: Intravenous (IV) therapy: 3 units packed cells – with IV Lasix (furosemide) 40mg
therapy after each unit (intraoperative & post op) In your answer:
Maintained V therapy for 3 hrs, then ceased and oral uids encouraged • Expand the relevant notes into complete sentences
Intravenous antibiotics (IVABs) – Cephazolin 1g t.d.s. for 3/7 – course completed • Do not use note form
• Use letter format
Vital signs: BP hypotensive – 95/60, other obs. within normal limits
Anti-hypertensive medication reviewd by Dr – Dose now Ramipril 5mg daily
The body of the letter should be approximately 180–200 words.
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 00ml haemoserous uid discharge from Exudrains over 24hrs
Drain tubes removed 48hrs post op (Day 2)
Alternate staples removed Day 5 and dressing changed
2 3
Notes
Name: Mrs Jane LaPaglia
Age: 71
Cultural & religion data: Italian & Catholic, speaks functional English
Admission Date: 4th March 2011 – Prince Albert Hospital
Discharge Date: 28th April 2011
Diagnosis: Renal failure 2⁰ to dehydration, mild dementia, pneumonia
Social/Medical family: * Lives with 80 yr old husband/carer, Joe, in a 4 bdrm unit
*Joe not coping with pt’s or his own care needs.
*House filthy, both have poor hygiene and nutrition
*One son, Andrew, a mechanic, visits Tuesday and Sunday
*Interests include classical music, ballet and AFL.
Medical History and Medications:
See Dr’s notes (to be forwarded)

*Initially comatose, ventilated in ICU 7/7

*Given dialysis 3/52 which ↓ urea & creatinine, stable now
*Hospital acquired pneumonia 2/24 chest physio
for 2/52, still requiring O2 2 litres via nasal prongs but non
infective for 3/52.
*↑confusion post ICU but now back to usual mild level and
Is quite settled.
*Needs prompting to eat, drink, dress, walk, toilet
& tend to personal hygiene but can independently do these
*Family conference 25/3/11. Consensus decision: pt will
move to nursing home & Joe will live in adjoining hostel – nil
beds for either till 28/4/11.
Discharge Plan:
*Transfer to nursing home
*Husband will live in hostel next door, both accepting of this
*Continue O2 therapy as per O2 sats
*Encourage independence, pt capable of self-care with ++
prompting
*Ensure adequate hydration to prevent ↓renal function
*Repeat electrolyte, urea & creatinine blood test weekly
Writing task
You are the Charge Nurse on the medical ward where Ms LaPaglia has spent most of her hospital
stay as a patient.
Using the information in the case notes, write a referral letter to the Charge Nurse at Boronia
Nursing Home, Coogee where Mrs Jane LaPaglia will be discharged to from your ward.
In your answer:


Sample Writing Task: Nasser Ali
Read the case notes below and complete the writing task which follows
Today’s date: 19/02/2012 You are Louise Nagatani, a registered nurse in the Coronary
Care Unit at a General Hospital. Nasser Ali is a patient in your care. Discharge
Summary
• Name: Nasser Ali
• Address: 1052 Moorvale Rd, Moorooka
• Phone: 046538762
• Date of Birth: 4 February 1964
• Date of admission: 09/02/2012
• Diagnosis: MI
• Date of discharge: 19/02/2012
• Name of surgery: CABG
Reason for admission

• Patient arrived at the hospital via ambulance 10 days ago suffering from acute
substernal chest pain radiating to left arm.
• He complained of severe chest pain, pain in jaws and left arm, diaphoresis, dizziness
and shortness of breath.
• Patient has been diagnosed with myocardial infarction. Condition has now stabilised,
however, he appears restless and worried about his condition.
• He is overweight and is a smoker.
• He has high blood pressure.
Treatment
• Sereptolunanse, anti-coagulants and anti-cholinergic drugs.
• Continuous ECG monitoring, angioplasty on 10/02/2012
• Post surgery physiotherapy
• Karvea 150 mg daily
• ½ Aspirin daily
Social History
• Family are refugees from Afghanistan arrived by boat in Australia in 2010.
• Marital status: Married, seven children. Aged 6 months to 22
• Next of kin: Fatima Ali (Wife)
• Employment o Nasser works as a Taxi Driver
o Fatima: Housewife
• Accommodation: Living in rental flat

• GP: No family doctor
• Language: Dari. Nasser attends TAFE English classes but only has basic English
conversational ability.
Discharge Plan
• Follow-up appointment made with cardiologist, Dr R Lang, Hospital Outpatients 2pm
26/2/2012
• Order medications from hospital pharmacy – Explain usage and stress the importance
of taking medication regularly as directed
• Arrange for dietician to provide dietary advice
• Discuss importance of giving up smoking and provide advice on available quit smoking
programs
• Advise patient to continue with the exercise program recommended by the hospital
physiotherapist , particularly deep breathing exercises with Triflo
• Arrange for a community social worker to provide a support service to the family to
ensure a smooth transition back to normal life.
WRITING TASK
Using the information in the case notes, write a letter to the social worker, Sarah
MacDonald Annerley Community Centre, 1122 Ipswich Rd Annerley, 4121 explaining the
patient’s situation and needs.
In your answer:
• Expand the relevant case notes into complete sentences
• The body of the letter should not be more than 200 words
• Use correct letter format
Notes
Name: Phillip Satchell
Age: 73
Marital status: Wife deceased (2007)
Family: Two sons in their 40’s in Darwin.
First attended community centre: March 2007
Last visit to community centre: Feb 2011
Diagnosis: Multiple sclerosis, Type 2 diabetes, chronic L & R leg ulcers
Social/Medical Background: Current: lives alone in public housing in Orange
Future: will move to equivalent housing in Maroubra to Î
access for MS treatment.
Income: aged pension
Poor compliance with oral diabetic agents and diabetic diet
MS currently stable but frequent relapses
2-3/12 Staphylococcus Aureus infections
in leg ulcers; pus ++
Lonely and isolated, but nil mental illness; good relations

with sons but rarely see them. They run a pet shop business.
Nursing management and progress: Medications: IV antibiotics twice daily and metformin for
diabetes three times per day.
Twice daily dressings to L & R legs
Monitored blood sugar levels, medication compliance

and provided education re diabetes.
Constantly monitored for signs of MS relapse
Discharge plan
Switch to oral antibiotics but continue same diabetic medications and dressings.
Please refer to Prince of Wales Diabetic Clinic (medication review + Î education).
Via your doctors, facilitate referral to neurologist for MS follow up.
Support to link with community services to Î coping and social network.
Writing task
Using the information in the case notes, write a referral letter to the Community Nurse, Community
Health Centre, Maroubra, outlining relevant information and requesting continued community care.
In your answer:

Notes
Patient: Rosalind Hinds
Age: 6 days
Next of Kin: Genette Keating (Mother)
Date of birth: 22 April 2011
Discharge Date: 28 April 2011
Diagnosis: Low birth weight & opioid dependence
Family: Will live with mother at maternal grandmother’s house
Background: * Mother (22 yrs) heroin dependent 2 yrs.
*Mother, single and recently worked as a sex worker.
*Estranged from father of Rosalind as alleged domestic

violence towards her during pregnancy.
*Genette’s mother supportive.
*First child
*Department of Community Services involved but approve

discharge living situation as long as with grandmother
Medical History and Medications:
See Dr’s notes (to be forwarded)

* Both mother and baby completed heroin withdrawal

without complications
*Baby 2.0kg at birth; 2.3kg 28/4/11
*Bottle feeding erratically ? ↓appetite
*Poor bonding between mother and baby.
*Genette often needs prompting to care for baby.
*Drug and alcohol team involved in managing Genette’s
ongoing addiction issue.
Discharge Plan: *Daily visits until pt stable weight and feeding stable
*Ensure safe environment for baby and update
Department of Community Services if risks present
*Monitor mother’s coping and psychosocial state
*Educate mother and grandmother on infant care
*Liaise with drug and alcohol team to provide integrated
support for mother to ↓ risk of heroin use.
Writing task
You are the Charge Nurse on the maternity ward where Rosalind Hinds was born and need to write a
letter to the local community midwifery team outlining relevant information and requesting
discharge follow-up. Address the letter to Maitland Maternal and Child Health Centre, Maitland.
In your answer:



Name: Bob Dawson

Phone: (07) 3442 1958
Social Background
pensions
Medical History:
slightly impaired.
18 /5/08
19.5.08
23.5.08
Knee healing well.
WRITING TASK
assessed.
Occupational English Test
Writing sub-test: Nurses
Time allowed: Reading Time: 5 minutes

Writing Time: 40 minutes
NOTES
Name: Shannon Warne
Age: 23 years
Marital status: Single
Admitted: April 6, 2007
Discharged: June 14, 2007
Diagnosis:
 Broken neck and fractured pelvis following car accident
 Probable permanent neurological damage affecting mobility, speech
and memory areas
Social background:
 3rd year architectural studies student, Adelaide University
 Interests: hockey, cycling, photography
 Was living in share flat - now needs long term rehabilitation
 Parents willing to care for him; may eventually return home
 Currently eligible for disability pension
Nursing management and progress:

 Good progress
 Will require ongoing high level care
 Recently started using wheelchair
 Daily physiotherapy, hydrotherapy 2x / week and speech therapy 3x / week
 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
 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 using the information in the case notes to outline relevant information and
request follow-up care.
Do not use note form in the letter; expand the relevant case notes into full sentences.
Writing Test 2
Patient History Shirley Decosta is a two week's old baby. Her mother
has got discharge from maternity hospital
Baby: Shirley Decosta, two week's old
Social History Mother: Ritz Decosta

DOB: 9/8/1983
Husband: Joseph Decosta, 42 years
Occupation: Taxi Driver
Other Children: Shelley Decosta, 9 years
Nursing Notes Normal delivery

Breast Feeding the baby
Baby sleepy
Weight Taken At the time of birth: 3009 gm

At the time of discharge: 3022 gm
Discharge Date 22 April, 2011
Using the information in the case notes, write a letter to Ms Susanna Bates, Child Health
Nurse, at Royal Women Hospital, CNR Grattan & Flemming St, Parkville, VIC 3052, who
will provide follow-up care in this case.
In your answer:

Patient name:—Stanley Williams.
D.0.8- 20/3/1956
Patient History: Stanley Williams is a builder and regular patient your country medical center in
Mildura, 350 km north of Melbourne. Presents occasionally with lower back pain-clears up with
anti inflammatories.
Had spinal x-ray 1 year ago—showed some narrowing of L4-5 and sign of osteoarthritis in L5-s1
Has NIDDM controlled by diet and exercise.
23/2/2007
Sudden onset lower back pain yesterday while working .Worse than usual back pain. Worse L.
Side with radiation down back of L.thigh. Took Nurofen which settled pain but worse this
morning. Couldn't go to work.
Puts on L.hip when walking, walks slowly. Tender around lower spine and spinal muscles. SLR
positive on L.side at 45 degrees. Legs normal power and reflexes. Pain inhibiting lumbar
flexibility and extension.
Assessment: Possible disc prolapse or nerve root irritation from facer joint disfunction.
Treatment: Bed rest 2 days, paracetamol and anti inflammatory 50 mg 2 X daily with food, hot
water bottle on back, come back in 2 days.
25/2/2007
No change in pain or leg pain, neurological examination done normal.
In pain but says it's no worse than before, still some difficulty with movement, L.side SLR 40-45
degrees.
Assessment: No improvement of symptoms but no worsening.

Treatment-Continue treatment as before. NSAIDS increased to 3X daily .Return in 2 days for
review.
27/2/2007
No change in back pain; radiating leg pain worse, more constant, esp. at night; urine test
showed glycosuria 2 plus (usually none).
Obviously in pain, difficulty with movement ,walks slowly. Still tender and with decreased
motion. SLR 30 degrees. L.side. Random blood glucose taken-12 mmol.
Assessment- Symptoms worse. Inactivity making diabetes symptoms worse.

Treatment: Continue treatment as before. Review in 5 days. Paracetamol/codeine 30 mgX 6
hourly. Reason for diabetes symptoms worsening explained- diet modification recommended
because of inactivity.
29/2/2007
Called urgently to patient's home, pain increased overnight in back and down L.leg; pain not
controlled by any medications, lower L.leg has become numb.
Pain caused inability to get out of bed.SLR 10 degrees L.Ieg and 30-40 degrees R.leg.L.leg also
no ankle reflex, decreased toes extension, decreased ankle flexion, decreased pin prick
sensation in areas. Random blood glucose increased to 14 mmol.
Assessment: condition not relieved by medication. Signs indicate nerve root compression and
disc prolapse.
Treatment: Ambulance transport to Royal Melbourne Hospital emergency department

arranged, phoned orthopaedic registrar and arranged for hospitalisation and orthopaedic
assessment.
Write a letter to Dr.Kate Murray, Royal Melbourne Hospital Royal Parl, 3004.
Patient Details
You are Joanna Andrew, a senior nurse working with the “Your Health Care Agency.”
Stephen Mabel is the patient. Read the case notes below and complete the writing task
which follows.
Name Stephen Mabel
Address 8 Stuart Street, Perth, WA 6000
Phone 0422 678 144
Date of Birth 18 June, 1972
Social Background
Married – Wife Sandra Mabel aged 39. Lives together Stephen Mabel works as an
accountant in a company in Perth.
Medical History Faced Cerebrovascular accident (CVA) some 2 years ago.

Agile, Mentally active, speech slightly slurred, complaining of severe illness,
Walks with limp, impaired balance
12/7/2011
Felt extreme headache in the morning, fell off the stairs, badly injured right knee, GP
requested Your Health Care Agency for daily visits, dressing and assisting in taking shower
daily.
15/7/2011
Left leg knee – redressed, no infection noticed.
Stephen was able to walk little distances with help from his wife, Sandra. Complained of
usual pain while walking, apart from this nothing and he is doing well.
19/7/2011
Kneed healed well.
Patient was suggested to walk, using walking sticks. Wife, Sandra, requested for more
home visits in order to bring more improvement in his mobility.
WRITING TASK
Using the information given below in the case notes, write a letter to the Ms Physiotherapy
Center 588 Hay Street Subiaco, ((08) 9388 2877) on behalf of the patient's wife, Sandra,
requesting a home visit to help her husband in walking properly.
In your answer:
 Expand the information given in complete sentences

 Do not use note forms
 Use only letter format.

.
reported that Alison is overeating, embarrassed about her eczema and missing her
father, who she was very close to.
Based on this, I would appreciate it if you could investigate her case. Should you
require any further information please do not hesitate to contact me.
Yours sincerely,
Charge Nurse
Toohey Point State School
Word Count: 227 words

Writing Task 1 Nurses
Today's Date
09/09/12
Notes
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 1959
Address 9476 Old Dam Road, Goondiwindi QLD 4390
Next of Kin Brother, Ernie O’Riley 72 Burke St, Cunnamulla QLD 4490
Admitted 2 September 2012

Diagnosis Obstructive coronary artery disease
Operation Coronary artery bipass grafts (x 4) on 4th September 2011
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 15/9/12
• 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.
Task 2 Case Notes: Robyn Harwood
Today’s date: 12/07/11
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.
Xray 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
Using the information in the case notes, write a letter to the Nursing Director Ms. Jenny
Attard of the Community Home Care Agency, requesting visits from the home care
nurse.
Task 3 Case Notes: Henry O'Keefe
Today's Date
13/3/12
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 Spirit Public Hospital. He
was discharged from hospital on 17/03/12.
Name: Henry O’Keefe

Address: 12 Donaldson Street, Greenslopes 4121
Phone: (07) 3941 2267
Date of Birth: 2 February 1929
Admitted: 14/3/12
Diagnosis: Malignant Melanoma Left Shoulder
Medical History
Large lesion successfully removed 14/3/12

Discharged 17/3/12
Needs assistance with showering and to dress wound prior to removal of sutures at
Mater Public Hospital on 24/3/12
Family History
Married aged pensioner. Lives in housing commission home with wife Dorothy also an
aged pensioner. No children
18/3/12
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.
19/3/12
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
Using the information in the case notes, write 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.
Nurses Writing Task 4
Read the case notes below and complete the writing task which follows
Today's Date
25/07/12
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 2008
Admitted: 15th July 2012
Gender: Male
Discharged: 25th July 2012

Country of birth: Sudan
Diagnosis: acute meningoencephalitis
Social History
Parents: Miri & Abdullah Obeki, refugees, arrived in Australia in 2012.

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
Using the information in the case notes, write a letter to The Director, Community
Child Health Service, 41 Jones Street, Ekibin, requesting follow-up of this family.
Task 5 Case Notes: Jim Middleton

Today’s date: 9/7/12
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 1928
Admitted: 7 July 2012
Planned Discharge Date: 9 July 2012
Diagnosis: Left inguinal hernia
Medical History
Hypertension diagnosed 2002

Medication Atacand 4mg daily
Family History
Married 50 years to wife Olga DOB 8/2/36 – 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
Using the information in the case notes, write 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.
Task 1 Case Notes: Nicole Smith
Today's Date
13/09/12
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
Admitted: 9th September 2012
Discharged: 13th September 2012
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 Rockhampton. 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 2012

Time: 1120hrs
Sex: Male
Weight: 4.4 kg
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 12/09/12: 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
Using the information in the case notes, write 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.
Task 2 Case Notes: Betty Olsen
Today's date
10/07/12
Notes
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: 29/01/1929
Marital Status: Widowed
Country of birth: Australia
Social History
Moved to a retirement village following the death of husband in December 2010.
Next of kin: Son, Nicholas Olsen,

53 Palmer Street, Warwick 4370
Ph (07) 4693 6552.
Retired triple certificate nurse - was the matron of a small country hospital for 15 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 bridge, bingo and reading.
Medical History
Hypothyroidism since 2000

Hypertension since 2007
Glaucoma since 2007
Allergic to penicillin
Prescription Medications
Karvea 150mg 1 daily

Oroxine 0.1mg 1 daily am
Timoptol Eye Drops 0.5% 1drop each eye am & pm
Normison 10 mg as required
Non prescription 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
16/05/12
Flu vaccination
29/06/12
Complaining of indigestion following evening meal. Settled with Mylanta
07/07/12
Unable to sleep – aches in shoulder. Settled following 2 Panadol and 1 Normison
09/07/12
Requested Mylanta for indigestion,Panadol for shoulder pain – slept poorly
10/07/12 am
Tired and feeling generally weak. BP 180/95. Confined to bed. GP called and will visit
11/7/12 after surgery.
10/07/12 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.
Task 3 Case Notes: Nina Sharman
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
Recent Nursing Notes

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.
Task 4 Case Notes: Sandra Peterson
Today’s Date: 22/03/12
Hospital
Spirit Hospital - Medical Assessment Unit (MAU)
Admission Date: 20/03/2012
Discharge Date: 22/03/2012
Patient Details
• Name: Sandra Peterson

• DOB: 01/01/1921
• Address: 258 Addison St, Applethorpe
• Marital status: widowed – 25 yrs
• Next of kin: daughter – Ann Macarthur ph 0438856277
Diagnosis
• URTI (Upper Respiratory Tract Infection) – dehydration, bi- basal crackles

heard on chest, SOB
• Polypharmacy - on 24 medications at admission including a variety of OTC
medication encouraged by her daughter
History of Presenting Illness
• 13/03/2012 –coughing (yellow sputum)

• 18/03/2012 - ↓ed mobility, found in a sitting position on the floor in her room,
no injuries
• 19/03/2012 - ↑ed confusion had another fall in the toilet, no injuries
• 20/03/2012 - BP 190/90, SOB, dizziness, the 3rd fall, an ambulance was called
Past Medical History
• Moderate dementia
• HTN
• Incontinent of urine – occasionally
Social History
• Lives in 2-bedroom flat with her daughter and son-in-law

• Daughter is overly supportive, overreacting and anxious about her mother’s
health
• Religion: Orthodox Christianity, attends church weekly with daughter
• Hobbies: listening to classical music, watching movies
• Requires some assistance with bathing, dressing and toileting
• Home Care worker visits 2 x wkly (bathing)
Medical Progress
• X- Ray – normal
• FBC – WCC 9.0, Hb 115g/L
• CT-brain – no acute changes
• Commenced on Augmentin 500 mg x BD, per os
• Now intermittent dry cough
• IV normal saline for 24 hrs
• Medications rationalised by doctor as detailed in discharge plan
• BP 150/70 - after adjustment of anti-hypertensives
Nursing management
• Vital signs: afebrile, haemodynamically stable, saturating 96% room air

• Mobility: short distance – independently ambulant with a seat walker, long
distance – wheelchair x 1 assistant
• Hygiene: full assistance require with bathing, some assistance with dressing and
grooming
• Psycho/Social: Mild confusion, but co-operative
Discharge Plan
• Community nurse referral

o Continue 500-mg tablet of Augmentin BD x 5 days, should be taken at
the start of a meal
o Metoprolol 25 mg BD
o Candesartan 16 mg mane
o Medications – monitoring and assistance
o Daughter requires education/monitoring due to Hx of polypharmacy
o Ongoing care with personal hygiene required
Writing Task
You are the charge nurse on the MAU where Mrs Sandra Peterson has resided during
her hospital stay. Using the information in the case notes, write a letter to the
Community Nurse at Spirit Community Health Centre, Cnr Bell & Burn Streets
Applethorpe, NSW, 2171. In your letter explain relevant background and medical
history and provide information about discharge requirements.
Task 5 Case Notes: Alison Cooper
You are the school nurse at a Toohey Point Primary State School
Today’s Date
07/03/2012
Patient Details
Alison Cooper
Year 5 student
DOB: 14/6/2002
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

2012
February 8: Complained of headache. Gave paracetemol, 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 parcetemol, 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.
2011
February 15: Complained of toothache. Called grandmother for pick up.

April 4: Complained of headache. Gave paracetemol - 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 paracetemol, 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
about eczema & weight. 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
Using the information in the case notes, write 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.

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Writing Test 3

Hospital Royal Perth Hospital

Patient Details Alfred Billy

Admission Date 21/03/2010

Discharge Date 5/05/2010

Diagnosis Skin cancer – BCC (Basal Cell Carncinoma) (neck)

Past Medical No prior hospitalization, no history

Social Truck Driver

History/Supports Lives with her wife

Medical Progress Skin biopsy is taken for pathological study

Nursing No complications noted

Management Perfectly well at the time of discharge

 Expand the relevant case notes into complete sentences.

Writing Test: Nurses

Time allowed: 40 minutes

Name: Ms. Amy Vineyard

Diagnosis: pregnant substance abuse

• Community mental Health Nursing required daily next 2 weeks minimum.

Reason for admission:

• pt. monitored and blood tests for HIV/AIDS and STDs

• Nicotine daily 30-40 cigarettes

• suicidal thoughts, self harm in past

Time allowed: 40 minutes

Name: Bob Dawson

Time allowed: 40 minutes

Name: Bob Dawson

Patient: MAVIS BRAMPTON - 72 years old

Today’s date: 15 January 2012

Marital Status: Widower (8 years)

Admission Date: 3 September 2010 (City Hospital)

Discharge Date: 7 September 2010

Diagnosis: Left Total Hip Replacement (THR)

Ongoing high blood pressure

Social Background: Lives at Greywalls Nursing Home (GNH) (4 years)

Employed as a radio engineer until retirement aged 65

Hobbies: chess, ham radio operator

Sister, Dawn Mason (66), visits regularly; v supportive

– plays chess with Mr Baker on her visits

No signs of dementia observed

Medical Background: 2008 – Osteoarthritis requiring total hip replacement surgery

1989 – Hypertension (ongoing management)

1985 – Colles fracture, ORIF

Ramipril 5mg mane

Panadeine Forte (co-codamol) 2 qid prn

Nursing Management and Progress:

daily dressings surgery incision site

Range of motion, stretching and strengthening exercises

Staples to be removed in two wks (21/9)

Also, follow-up FBE and UEC tests at City Hospital Clinic

Assessment: Good mobility post-operation

Weight-bearing with use of wheelie-walker; walks length of ward without difficulty

Post-operative disoriention re time and place during recovery, possibly relating to

Dropped Hb post-operatively (to 72) requiring transfusion of 3 units packed red

Discharge Plan: Monitor medications (Panadeine Forte)

Preserve skin integrity

Continue exercise program

Equipment required: wheelie-walker, wedge pillow, toilet raiser. Hospital to provide

Date of birth: 15 April 2006

Place of birth: Sydney Children’s Hospital, Sydney

School year: Kindergarten

Mother’s name: Elizabeth Kovacs

Mother’s community admission date: 16 May 2011

Diagnosis: Mother – Major depression with psychotic features