Рет қаралды 31,046
TIME ALLOWED:
READING TIME: 5 MINUTES
WRITING TIME: 40 MINUTES
Read the case notes below and complete the writing task which follows.
NOTES:
You are a nurse at Bayview Medical clinic. You are assessing a 22-year-old man who has worsening asthma.
PATIENT DETAILS:
Name: Mr Zach Foster
DOB:25/10/91 (Age 22)
Address: 77 Creek Road, Bayview
Medical History:
Allergies: Medications:
Family history:
Social history: Presenting complaints:
Treatment Record: 11.10.14 Subjective:
Objective:
Tests: Diagnosis: Treatment:
18.10.14
Review:
Asthma, since age three - problematic at times, 2
previous hospital admissions (most recent- 3 years ago) Eczema
Smoker - 4 years, 10-20/day
Cats, Hayfever.
Ventolin prn
Pulmicort 200 mcg one puff bd
Sister (age 18) - asthma Builder, single
For last 3/52 (3 weeks):
- - -
SOB - when playing sport.
Wheeze & cough - waking patient at night.
Increase use of Ventolin for symptoms.
Preventative inhaler(Pulmicort): compliance unclear: claims to use inhaler some of the time. Burning sensation in lower part of the chest after meals- consistent with gastro-oesophageal reflux disease (GORD).
Chest clear.
Peak flow 500L/min. Abdomen lax and non-tender.
CXR, FBE
Unstable asthma, possible trigger GORD
-Ensure compliance with Pulmicort. -Trial of pantoprazole (PPI) for GORD. -Discussion about smoking cessation. -Review 1/52.
Still smoking.
Non-compliant with Pulmicort- forgets to
Test result: Treatment:
take it.
PPI - effective, nil side effects.
CXR- clear FBE- normal
Use pantoprazole for another 7/52 (7 weeks) then review. -Discussion about Pulmicort missed dosage
take as soon as remember, then back to normal, do not double dose. -Advice on smoking cessation (e.g. nicotine
patch, information brochures, support Groups, etc.) -Continue current management: refer to
respiratory specialist for lung function and advice about asthma management
-Review appointment 7/52.
WRITING TASK:
Using the information given in the case notes, write a letter of referral to Dr Willliams , a respiratory specialist, for further management of Mr Foster’s asthma.Address the letter to Dr Tanya Williams, Respiratory Specialist, Bayview Private Hospital, 81 Canyon Road, Bayview.
In your answer:
Expand the relevant case notes into complete sentences Do not use note form