OET NURSING CASE NOTES

Disclaimer: These case notes are intended purely for educational use and do not constitute medical advice. They are written in a similar style to OET format, but are not official OET material.

 Written by Suzanne Carroll (Medical English Direct, www.medicalenglishdirect.com, FB Medical English Direct)


Mr Ivan Thompson is a patient on the surgical ward of Greenville Hospital.  You are the Charge Nurse.

PATIENT DETAILS

Name: Ivan Thompson

DOB: 1/8/1984

Marital Status: Married

Admission date: 8/6/2019

Discharge date: 10/6/2019


Social background:

IT worker

Travels a lot for work

Plays football

2 children

Lives in a 3 bedroom rented house

Drinks 2-4 units of alcohol, per week. Socially.


Medical Background:

2004 Colles fracture, ORIF

2001- Appendectomy

Smoker –smokes 5 cigarettes per day. More on weekends.


Reason for Admission:

Perianal abscess. Pt referred by GP.  Painful swelling near anus. Pus collection (slightly yellow in colour, no offensive odour). Pt discomfort. Area swollen.

VS on admission: Temp: 37.6, HR 88 bpm, Sats 98%, RR 22, BP 149/80

Treatment:

9/6/19 Incision and drainage (I & D) under general anaesthetic.

Allergies: NKDA


Medications:– Post- op, paracetamol 1g (QDS, PRN) and ibuprofen 200mg-400mg (TDS, PRN) post procedure. (Patient advised to not use ibuprofen long term)

Metronidazole: 500mg every 8 hours for 7 days. Course to be completed at home (orally)


Nursing Management and Progress:

Daily dressings (to the right of the anus). Analgesia recommended to be taken before dressing changes first few days.

Currently 2cm in length and 1.5cm in width

Wound being cleaned with prontosan, packed with kaltostat and tegaderm for sealing.

Assessment: Pt showing no signs of infection on discharge. All observations normal.

Bowels opened post-surgery, aid of stool softener


Discharge Plan:

Daily wound dressings as exudate ++.

Continue with dressing choice as you see fit (see above for current dressing choice)

Monitor for signs of infection

Encourage Pt to finish course of ABX

Refer back to hospital if any concerns with healing

If pt has a lot of pain when opening bowels we have advised to use stool softener and eat a fibre based diet

Pt has a follow up review at Surgical Outpatients Department, Greenville Hospital in 6 weeks.


Writing Task:

Using the information in the case notes, write a letter to the GP Nurse, Greystone General Practice, 57 Sand Lane, Greystone asking for wound care and monitoring post-discharge.

Expand the relevant notes into complete sentences

Do not use note form

Use letter format

180-200 words.

 

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