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.
Name: Ivan Thompson
Marital Status: Married
Admission date: 8/6/2019
Discharge date: 10/6/2019
Travels a lot for work
Lives in a 3 bedroom rented house
Drinks 2-4 units of alcohol, per week. Socially.
2004 Colles fracture, ORIF
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
9/6/19 Incision and drainage (I & D) under general anaesthetic.
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
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.
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