OET Letter AI Evaluator

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OET Letter Evaluator AI

Assume that today's date is 30 August 2019.
You are a nurse conducting a Nurse Home Visit as part of routine follow-up care after this patient’s recent hospital discharge.
PATIENT DETAILS:

Name: DOB:
Address:
 
Ms Patricia Styles
27 Apr 1957 (Age 62)
57 Market Drive, Newtown

Social background:
Retired primary school teacher Lives on her own
Husband died 3 yrs ago (lung cancer); no children
Medical history: Hypertension (HT)
    • Diagnosed 2011 – mild 145/95
    • 2013 – moderate 168/105, commenced quinapril
    • Regular monitoring, currently well managed at around 140/90
Diabetes mellitus (DM) Type 2
    • Diagnosed 2013 – Pt counselled re diet/lifestyle, incl. weight loss
    • 2014 – commenced oral hypoglycaemics (metformin + gliclazide)
    • Well managed generally
Depression
    • Diagnosed June 2016
    • Triggered by death of husband
    • Regular counselling since July 2016 to control mood swings and support DM management
Family medical history:
Mother – HT, DM

Lifestyle:	Smoking/Alcohol:	Non-smoker; 1-2 glasses wine/wk
	Exercise:	Walks dog 20mins/day
	Diet:	Ongoing counselling re DM management to maintain balanced diet
Medications:	Quinapril (Accupril) oral 40mg/2xday
Metformin (Diabex) oral 500mg/2xday Gliclazide (APO-Gliclazide MR) oral 30mg daily

Green Valley Hospital Treatment Record:
    • Aug 2019	Pt visiting sister for weekend, sister lives 3hrs away from Newtown in Green Valley
Pt admitted to Green Valley Hospital late evening with fever, sharp & pleuritic chest pain (worse on breathing), general weakness & malaise, tachycardia (rapid heartbeat)
    • Aug 2019
Assessment:	Vital signs RR 29; BP 170/106; HR 98; T 39.3ºC
Full blood examination (FBE): 🡡 ESR (erythrocyte sedimentation rate), 🡡 CRP (C- reactive protein), 🡡 WCC (white cell count) i.e. inflammation/stress
Throat swab: viral influenza type B Chest X-ray (CXR) – normal Echocardiogram – pericarditis
Management:	IV saline
Ibuprofen 600mg every 8hrs
Evaluation:	Viral influenza type B plus pericarditis
    • Aug 2019	Pt discharged and advised on self-care at home
Niece drove Pt home & agreed to stay overnight for 3 nights Follow-up Nurse Home Visit arranged for 30 Aug 2019
Nurse Home Visit – 30 Aug 2019:
Observations: Pt unhappy. Reports feeling chest pain (relieved by sitting up), shortness of breath (SOB), fatigue. Frustrated with progress of recovery
Medication adherence – reports compliance & regular blood glucose monitoring Vital signs: low-grade fever: T 38.1°C. Elevated RR 28 & HR 115
BP: 125/78 (usual BP 140/90)
Niece no longer staying overnight – work commitments in Green Valley
Assessment:	Pt unwell. Nil improvement
?relapse/complications of pericarditis
Plan:	Organise urgent hospital transfer to Newtown Hospital (nearest hospital) Write referral to Emergency Department, include relevant:
    • Medications
    • Patient history
    • Test results/observations

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