• VITAL SIGNS: BP 120/85, pulse 80, RR 20, temp.

37
degrees and O2 sat 98% on room air. Blood glucose-
is controlled by medication.
• At the ER: Dilaudid 1 mg IM at L deltoid. A cold
EXAM-1 WRITING REFERRAL compress was applied.
• Wound dressing with Silvadene done.
You are given 5 minutes to prepare and 30 minutes to
complete the task. Use the letter template we provided as (March 21, 2022), 3 PM Discharge Management and Plan:
your guide to making a referral letter.
• Dr. Sanchez prescribed Percocet 5 mg, #20 (Q12 PRN
Case notes: You are an ER Nurse working at Bautista Clinic for pain)
and Hospital. • Instructed to keep the dressing intact and Avoid
getting the dressings wet
• To RHU Nurse. To examine the site after 24 hours
Today’s date: 21/03/2021 (March 21, 2022)
and do wound dressing (every 2 days) with a topical
antibiotic.
Patient Details
• Must refer to a Dermatologist Dr. Gab Siason,
Patient: Mr. Kevin Salazar contact at (083) 4568-980 – to be done by the RHU
DOB: 14/02/1987 Nurse.
Phone: (083) 2982-887 • Instructed Mr. Kevin to elevate his R hand, keep cool
Address: 77-B Pedro Road, STA. Monica, Puerto compresses, and return sooner if there are any
Princesa, Palawan, Philippines problems.
*Married-34 -year-old. Obese. • To continue other medication maintenance as
*Restaurant Chef prescribed.
• If the Patient experience any unusual symptoms
Medical History: kindly contact the hospital or Dr. Sanchez at 083-
• Diabetes 2, HPN 7999 776 (Bautista Clinic and Hospital)
• Allergies Shrimps
(March 21, 2022), 4 PM: Disposition. The patient was
Family history: managed and released in stable condition - tolerable pain
• Father died due to DM 2- 2019 rated 3/10.
• Mother died aged 60 of myocardial infarction
Diagnosis: First to 2nd-degree burn- partial thickness
Social Activities:
• 1 pack of cigarettes (nicotine dependence). Denies Writing task: referral letter
alcohol and drug abuse. Write a referral letter to Nurse Guia Zaramuza at RHU STA.
• Cycling, playing golf and tennis at least once a week. Monica, Puerto Princesa, Palawan for management and
referral.
• Daily exercise 30 mins to 1 hour in the morning.
In your answer:
(March 21, 2022), 6:30 AM-Check up
DO NOT use BULLET-style paragraphs in the letter.
• Chief complaints: Burn wounds approx. 2-3 inches DO NOT COPY and PASTE, Reconstruct the
(Diameter) – Right hand sentences/information. Showcase your letter-writing skills.
• Assessment- Erythema, blisters, and edema with * Expand the relevant case notes to explain his background,
clear to yellow-colored fluid at dorsal area R hand. medical history, and assistance requested. *Only include
• Severe pain -pain scale 8/10 (+) facial grimace important information.
• No numbness, tingling, or weakness at the burn site. *The body of the letter should be approximately 150 – 200
(-) other injuries. words.
• Able to extend her fingers. The sensation is intact. *You are the writer of the letter. 21/03/2021 (March 21,
(+) good capillary reflex and distal pulses. 2022)
• He had an accident while cooking. – hot water
spilled. EXAM 1 TEMPLATE/GUIDE (on the next page)
• Accompanied by his co-workers.