ENGLISHMELON OET WRITING TEST 2

Writing Time: 45 Minutes

Read the case notes and complete the writing task which follows:

CASE NOTES

Patient details

 Name : Mrs Maria James

 Age : 56
 Address : 956 Addison St, perth
 Admission Date : 15/04/2014
 Discharged Date : 18/04/2014
 Diagnosis : chronic kidney disease and bronchial asthma
Medical History

Reason for admission:

 Fever, breathing difficulty for 2 days, tiredness for 1 week, vomiting 5 times.

Past Medical History

 Hypertension -2007 (Lisinopril)

 Diabetes mellitus - 2001(Glyciphage 500mg b d)
 STEMI - 2005 ( underwent PTCA)
 Bronchial asthma - Since 2003
 Osteoarthritis - Since 2007
 Gastritis - Diagnosed in 2008. Not yet controlled.

Social History

 Family - Lives with his husband in a rented house

 Mother – Hypertension
 Husband- diabetes mellitus type 2
 Martha, Her neighbour, is very friendly, visits her in hospital daily.
 Habit of consuming Alcohol in excess (for the past 20 years)
 Cigarette smoker

Medical Management

 Lasix 100 mg IV Stat

 Budecort and Duolin Nebulization
 Oxygen Administration
 Commenced treatment on Corticosteroids , Immunomodulators and methylxanthines

On admission,
 HB - 6 g/dL
 RBS - 605 mg/dL
 Urea – 105 mg/dL
 Creatinine - 5.4 mg/dL
 Calcium-6 mg/dL
 Phosphorus- 10mg/dL
 Potassium – 9mEq/L
  X Ray - Pulmonary Edema
 Total cholesterol - 225 mg/dL
 CBC : 6500 mL

Nursing management

 Vital signs: BP - 200/100 mm og Hg, pulse 120/ mnt, respiration - 26/ mnt, temp -
100
 2 unit packed cell transfused
 High Fowler's Position recommended
 Chest physiotherapy and deep breathing exercises

16/04/2014 Assessment

 Bp - 180/100 mm of hg , pulse - 100 , respiration - 24, temp - 99

 Pedal edema 3+
 Weight : 51kg
 Abdomen was protuberant
 Shortness of breath
 Advised chest physiotherapy and deep breathing exercises

17/04/2014 Assessment

 Bp - 190/100 mm of hg, pulse - 105 , respiration - 22, temp- 99

 Breathing difficulty and advised to provide high fowler's position with oxygen therapy
 Oliguria
 Efcorlin 100 mg
 Lasix 40 mg
 Gained 2 kg body weight
 Bowel pattern impaired. Now treated with laxatives.

18/042014 Assessment

 Bp - 200/100 mm of hg; Pulse - 100; Respiration - 20; Temp - 99

 Weight : 54kg
 Pitting edema 4+ (Pedal Oedema)
 Oliguria
 Melena
 Need to continue same antihypertensive drugs and hypoglycaemic agents.
 Stool occult blood positive
 HB-7.2g/dL
 RBS-510mg/dL
 Creatinine - 5.2 mg/dL
 Potassium – 8mEq/L
 1 unit packed cell transfused
 Discharge from the hospital

TASK

Using the information given in the case notes, write a referral letter to the nephrologist, Dr
Abraham John, Hyde hospital, Adelaide St. Perth.

In your answer, expand the relevant case notes into complete sentence.