NEW CASE NOTE -ANDREW MURRAY
OET Writing Case Notes: Andrew Murray
Date: 21 January 2025
Patient Name: Andrew Murray
Date of Birth: 15 March 1943 (81 years old)
Presenting Complaint:
• Long-term hospital stay (15 months) due to urinary failure.
Medical History:
• Primary Condition: Chronic urinary failure diagnosed 2 years ago.
• Hospital Stay:
• Admitted 15 months ago due to complications from urinary failure.
• Recurrent urinary tract infections (UTIs) during hospitalization.
• Requires ongoing urinary catheterization.
• Comorbidities:
• Type 2 diabetes mellitus (diagnosed 10 years ago).
• Hypertension (diagnosed 12 years ago).
• Osteoarthritis (knee and hip).
• Allergies: Penicillin (rash).
Social History:
• Widowed, lives alone, no immediate family support.
• Previously independent but now unable to manage daily activities.
• Mobility: Limited, wheelchair-bound, requires assistance for transfers.
Medications:
• Insulin therapy for diabetes.
• Amlodipine 10mg daily for hypertension.
• Paracetamol 1g PRN for osteoarthritis pain.
• Prophylactic antibiotics for recurrent UTIs.
Current Status:
• Physical Condition:
• Stable but frail.
• Maintains adequate oral intake with assistance.
• Continues to experience occasional discomfort related to catheterization.
• Mental Health:
• Mild cognitive impairment but oriented to person, place, and time.
Discharge Plan:
• Transfer to Greenfield Care Home for long-term residential care.
• Requires:
• Ongoing catheter care and infection monitoring.
• Assistance with all activities of daily living (ADLs).
• Regular physiotherapy to maintain mobility and prevent deconditioning.
• Blood glucose and blood pressure monitoring.
Special Instructions:
• Alert care home staff about penicillin allergy.
• Monitor closely for signs of UTI and hyperglycemia.
• Ensure a smooth transition of care with detailed handover to care home nursing staff.
Reason for Transfer:
To provide Andrew Murray with comprehensive long-term care and support in a residential setting, as his medical and functional needs can no longer be managed at home.
