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Englishmelon Oet Writing Test 2

Mrs. Maria James, a 56-year-old woman with chronic kidney disease and asthma, was admitted to the hospital with fever, breathing difficulty, tiredness, and vomiting. She has a history of hypertension, diabetes, heart attack, asthma, osteoarthritis, and gastritis. During her hospital stay she received treatments for her conditions and symptoms, and her health gradually improved before she was discharged after four days.

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Cam Achondo
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5K views

Englishmelon Oet Writing Test 2

Mrs. Maria James, a 56-year-old woman with chronic kidney disease and asthma, was admitted to the hospital with fever, breathing difficulty, tiredness, and vomiting. She has a history of hypertension, diabetes, heart attack, asthma, osteoarthritis, and gastritis. During her hospital stay she received treatments for her conditions and symptoms, and her health gradually improved before she was discharged after four days.

Uploaded by

Cam Achondo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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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.

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