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Susan Surrandon Questions for OET Writing Nurses
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| ber WRITING: NURSE /DOCTOR Time Allowed: 40 minutes
Read the case notes below and complete the writing task which follows:
Patient;
DoB:
‘Marital status:
Family:
First admitted:
Discharge date:
Diagnosis:
Medical
History:
Background:
‘Management
and Progress:
Susan Surandon
417-7-90
Single
Only child. Parents are still married and living together.
Pt. is student in the 10th grade.
13.9.08
Patient did not present to ER until 13.9.05, at which time she
displayed signs of peritonitis and septic shock with a fever of
39°C.
18.8.05
Ruptured appendix
Peritonitis
Pt received adenoidectomy in 1987.
Meds: Pt. takes methylphenidate 10mg bid for ADHD. May be
continued. «1
Denies EtOH/Tab use. Denies sexual activity.
Pt was on class trip to Perth from her schoo! in Bunbury when
she developed per-umbilical pain and anorexia, beginning on
40.9.2005. Initial pain followed by nausea ca 6 hours later. The
pain then migrated to the RLQ with a maximum over
MeBurney's point.
«Labs showed leucocytosis with left deviation, Hb of 13.1,
Het 41%, B-HCG was negative.
«The patient was immediately given ampicilinigentamicin
Nv.
«AUIS was carried out, which displayed free fluid in the
intra-abdominal space,
« Astanding AXR was also performed which showed free
air in the hepaticophrenic recess.
+ Anemergent laparotomy was performed. A perforation
of the severely inflamed appendix observed, along with
intraperitoneal abscess formation.
* Appendectomy performed; abscess drained. * Pttransferred to SICU. Fever subsided. Transferred to a
normal room.
© Ciprofioxacin iv on Post op Day 1 + 3 days.
Discharge plan: Pt is ready to be discharged to rehab centre. She should
re-present to this clinic on 1.10.05 for general assesement.
Contact Dr. Brown if fever >38°C, signs of infection or
inflammation, SBP < 100 or >160 mmHg.
WRITING TASK:
You are transferring Miss Susan Surandan to the Bunbury General Rebabilitation
Ceatre, Write a discharge summary to accompany the patient.
In your answer:
‘¢ Expand the relevant case notes into full sentences. Do not use note form in
the letter.
© Use correct letter format.
© The body of the letter should be 180 - 200 words Tong, Bunbury Rehabilitation Centre
Bunbury
18/09/05
Dear Sir/Madam,
Re: Miss Susan Sarandon
15 years old
1am writing to refer to you Susan Serandon, a 15 year old 10 grade student, who is an
only child. she had an adenoidectomy in 1997 and is on medication for ADHD. At
present, she is recovering from an eppendizectomy.
Susan presented to the Emergency Department of the hospital on 13/09/05 with signs of
Peritonitis and septic shock and a temperature of 39 degrees Centigrade. This wes three
days after
Investigations showed leucocytes with left deviation, free fluid in the abdominal space
and fice air in the intraperitoneal recess. An emergent leporotomy revealed a severely
inflamed, perforated appendix, with an intraperitoneal abscess. An appendicectomy was
performed and the abscess was drained.
The patient is now in a normal room as her fever has subsided, ‘Ciprofloxacin was
administered on day's ane to three post operation
‘Susan is ready for discharge to your centre. Please could you ensure that she re-presents
to this clinic for a general review, Ifthe paticnt’s temperature exceeds 38 degrees, or if
there are any signs of infection or inflammation, please contact Dr Brown.
Should you require any further information ahout Susan, please do not hesitate to contact
me.
‘Yours sincerely,
(Ms) Jenny Marshall
