Tiêu đề Exam 2.docx ✅

EXAM-2 WRITING REFERRAL You are given 2 minutes to prepare and 30 minutes to complete the task. Use the letter template we provided to guide you. Case notes: You are a Nurse working at St Lorenzo Hospital. Patient is managed under Dr Dequilla Today’s date: 07/04/25 ( April 7, 2025) Patient Details  Patient:  Ms Sammantah Dichoson DOB: 08/06/1985 Phone: (083) 2813-888 Address: Block 10 Lot 11 Manga Street, Zamboanga City *Married- 37-years-old. She lives with her husband. teacher Medical History:  ● Hx of DM 2, HPN ● Breast Cancer, (+)radical mastectomy with postoperative radiotherapy – year 2016 ● Cancer complication ( bone metastasis) on the sacroiliac joint, right trochanter, and left sacral area- year 2020. ● NKA, NKDA ( no known drug allergies ) Family history: Mother – with a history of DM2 Social Activities: ● A smoker since age 24, 1 pack per day. Drinks 3-4 pints/day since 20 years old. ● Hiking and camping weekly Medications: Metformin, Neobloc . ( April 5, 2025), 8 AM-Check up Chief complaints:   Difficulty breathing, easily fatigued. Shortness of breath ● Thin, pleasant female (+) mild respiratory distress ● A chest x-ray (+) shows a large pleural effusion on the Left. ● Decreased breath sounds at the 3/4 level on the L side. Right Lung-clear with few scattered rales. ● Cardiac examination - regular rate and rhythm without murmurs. No hepatosplenomegaly and no peripheral clubbing, cyanosis, or edema. ● CT scan- lung trapped by tumor, some adhesions. ● For thoracoscopy with pleurodesis ( STAT).- (+) pleural peel of tumor and multiple adhesions ● Vital signs: BP- 110/90, RR- 30bpm, pulse 88 bpm, pulse oxy 90%- on 02 3-5 LMP via nasal cannula. ● Significant nausea and vomiting with the Arimidex and Megace ( side effects) April 6-7, 2025- In the hospital. Medical care was given. April 7, 2025- 4 PM: Discharge Plan: ● Coordinate with the Local RHU nurse for a referral to an extended-care facility near her home: Contact @ (083) 6570-321 ( Badayos Care Facility)- to remain until she regains strength. ● Advised patient on the importance of physiotherapy- chest tapping to decrease fluid in the lungs. ● On Tylenol with Codeine as needed for pain, Megace, and a Multivitamin. Local RHU to include this info when referring to the care facility. ● RHU nurse to coordinate with Dr Dequilla every two weeks to monitor medical status. ● For a follow-up appointment with Dr Artamage in three weeks, with a chest x-ray result- must be accompanied by the local RHU nurse. Contact # (083) 7770-331 for any concerns( Dr Dequilla ) ● Discharged: prognosis is poor because of her debilitated state and the status of her lungs. Home instructions and Medications were given. The importance of medication and compliance with making appointments was emphasized. Writing task: referral letter Include the full Medical History of the patient. Write a referral letter to Ms Jinky Posadas, RHU Nurse, Población, Zamboanga City · (02) 8801 7483, for coordination/referral and management. In your answer: DO NOT use BULLET-style paragraphs in the letter or just copy and paste the contents. Showcase your letter-writing skills.- Try rewording. * Expand the relevant case notes to explain the background, medical history, and assistance requested. *Only include important information. Showcase your writing skills. *The body of the letter should be approximately 150 – 200 words. *You are the writer of the letter. The date is 07/04/25 ( April 7, 2025) EXAM 2 TEMPLATE/GUIDE ( on the next page)