Writing Case Notes Occupational English Test Nye =d in sbeoiwiss Read the case notes and complete the uniting task which follows. vVovare Ns Kate Andrews ond Mr Achuri.0 22a patient nthe hoya where you work Shea Oe ato the emergency department complaining of pain ocos her beck. Patient Details: (gwen Nome: Florence Arthur _ ae or DOB: 01/08/1992, Medical History: «Renal stones treated 2002, no back pressure: Creal * ‘¢ Uncomplicated eplode of cystitis 3 months ogo. Medical Records: 14/09/2020: she became unuel2 day prevasly when se arte to develop fever orl on ace her Bass ‘The pain has become progressively more severe. « ‘She has vomited twice in the post 6 h. Start IV empirical antibiotics -> ceftriaxone Tg and analgesics -> Diclofenac sodium Order FBC, CRP, No, K, urea, Creatinine, albumin, urinalysis 15/09/2020: t looks unwell and fs flushed. ‘Temperature s 395°C. Pulbe fs 120 beats/min and blood pressure 104/68 mmHg. Examination of the cardiovascular and respiratory systems is unremarkable. Her abdomen is generally tender, but most markedly in both loins, : Bowel sounds are normal. Investigations: Haemoglobin 15.3 g/dL White cells count 25.2 % 109/L, Platelets 406 % 109/1. Sodium 134 mmol/L, All Rights Reserved © https://oetwritingmastery.comWriting Case Notes GET, Potassium 441 mmol. Urea 14.2 mmol/L Creatinine 1068mol/L Albumin 44 g/L C-reactive protein (CRP) 316 ma/L Urinalysis » 50 RBCs- » 10000 WBCS Abdominal X-ray: NAD Ustrasound: bilateral hydronephrosis ‘The raised white cell count and CRP ore co Microscopic haematuria and leucocytes in the urn Patient will need bilateral nephrostomy tubes inthe swith an acute bacterial Infection. ne oo lammation in the urinary tract. context of hydroneP! Plan: «Transfer the patient to the Urology Department: +) Blood ond urine cultures should be taken, and she sh be commenced on intravenous fics and aoa aoe ant the orgonsm sient. ond then an ool -tibiote to which the organism Is sensitive can be wsed. «Initial therapy could be with gentamicin and ‘ampiailin, or ciprofloxacin. In your answer: ‘s Expand the relevant notes into complete sentences «Do not use note form ‘¢ Useletter format “The body ofthe letter should be approximately 160-200 words All Rights Reserved © https://oetwritingmastery.comrs» Nadia shruder Head Nurse Urlegy Depart ment Royal \nfirmary Hospital Scotland. th 1S September 2019, Ms. Shrouder Re- Mrs.Plorence Aurther DB. fo O.Bi- otfog [1492 , 29 year Od. Mrs. Aurther admitted to the emergency department op 4 /0q/22 due to Fever and patn accross her back, She has beer dlagnosed, With Bilateral hydronaphasis, and 4o be tranfered * your department for Bilateral nephrestomy tube insertion - She has a history of renal stones and eared ie dhe eperts uncomplt cated episodes of cystitis ‘three months age". On admissten she complained of fever, back pale and the Pain had become progressively more severe. She had vomitted dwtce within 6 hours prior tp the admission. Present’ complains are, Patient looks unwell and {Ss ftushed « Her vital siqns are , Fem perature 39.6 °C, Pulses (be bpm and Blood Pressure iS ton (eg mrmitg. No any changes In Cardlovastular and respiratory symptoms. Her abdemen Is generally tender, but mest markedly Wn beth loins. Bowel Sounds are normal. FBC, CRP, Na,k, Wea, Creatinine , albumin and urinalysis tests were ordered anc done. Wiite cell count has vais ak and CRP are Consistent with an acute bactertal infection.a haematurlan, Due fo inflammation tm Urinary ‘tract’, mierosco ple acaas ~ and \encocytes Presented in the Urine. Intravenous Ceftrtaxone \g and didofenac , Sedum pated administered and to be continued. Blood and urine Ot d fe be taken and ste continue Intravenous fluid ANC utd be col Antibiotics untill Organtsm identified. Lnittal therapy in. Start with gentamiine and ampiaittin or CiproPlox op Please provide appropiate. care for her untittrer et Contact me for any quires. Thank You. Yours’ a Sincerely Kis. ( Wis: Kete> ‘Addn’. ? Nurse, P.Emergeicsy depart