TIME ALLOWED: READING TIME: 5 MINUTES Task 2

WRITING TIME: 40 MINUTES

Read the case notes below and complete the writing task which follows.
notes:
Hospital: Fairbanks Hospital, 1001 Noble St, Fairbanks, AK 99701
Name: Mrs Sally Fletcher
Date of Birth: 3/10/1993
Marital status: Married, 5 years
Appointment date: 25/03/2018
Diagnosis: Endometriosis
Past medical history:
 Painful periods 3 years
 Wants children, trying 1 year ++

Social background:
 Accountant, regular western diet.
 Exercises 3 x week local gym

Medical background:
 Frequent acute menstrual pain localised to the lower left quadrant.
 Pain persists despite taking OTC = naproxen.
 Shy discussing sexual history.
 Occasional constipation, associated with pain in lower left quadrant.
 Trans-vaginal ultrasound showing 6cm cyst, likely of endometrial origin.
 Patient recovering post op from laparoscopic surgery(25/03/2018) – nocomplications

Post op care: Keep incisions clean and dry.

Mobility post op:

 Showering is permitted 26/03/2018
 Driving is prohibited when on analgesics.
 Driving can be resumed 24-48 hrs after final dose analgesics.
 Sexual activity can be resumed 2 weeks post op.
Nursing management:
 Encourage oral fluids.
 Patient may return to regular diet.
 Ambulation encouraged as per patient tolerance.

Medical progress
 Afebrile. Hct, Hgb, Plts, WBC, BUN, Cr, Na, K, Cl, HCO3, Glu all within normal limits.
 Patient sitting comfortably, alert, oriented × 4 (person, place, time, situation).

Assessment:
 Good progress overall.
Discharge plan:
 Patient to be discharged when can eat, ambulate, urinate independently.
 Patient must be discharged to someone who can drive them home.

Writing Task:
You are a first year resident in a surgical ward. Sally Fletcher is a 25-year-old woman who has
recently undergone surgery. You are now discharging her from hospital.

Using the information given to you in the case notes, write a letter of discharge to the patient’s
GP, Dr Stevens, Mill Street Surgery, Farnham,GU10 1HA.

In your answer:
● Expand the relevant case notes into complete sentences
● Do not use note form
● Use correct letter format

The body of your letter should be approximately 200 words. Use correct letter format