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.