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    Amy Vineyard

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    Airah Catubay
    The document describes a case note about a 6 week pregnant patient named Ms. Amy Vineyard who is seeking help for substance abuse issues and mental health concerns. She has a history of alcohol, drug, and tobacco use and is homeless. The case note outlines her medical history and substance use as well as her mental health and living situation to inform her ongoing community care.

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    Download as PDF, TXT or read online from Scribd

    Amy Vineyard

    Uploaded by

    Airah Catubay
    130 views2 pages
    The document describes a case note about a 6 week pregnant patient named Ms. Amy Vineyard who is seeking help for substance abuse issues and mental health concerns. She has a history of alcohol, drug, and tobacco use and is homeless. The case note outlines her medical history and substance use as well as her mental health and living situation to inform her ongoing community care.

    Original Description:

    OET WRITING

    Original Title

    Amy+Vineyard

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    The document describes a case note about a 6 week pregnant patient named Ms. Amy Vineyard who is seeking help for substance abuse issues and mental health concerns. She has a history of alcohol, drug, and tobacco use and is homeless. The case note outlines her medical history and substance use as well as her mental health and living situation to inform her ongoing community care.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    130 views2 pages

    Amy Vineyard

    Uploaded by

    Airah Catubay
    The document describes a case note about a 6 week pregnant patient named Ms. Amy Vineyard who is seeking help for substance abuse issues and mental health concerns. She has a history of alcohol, drug, and tobacco use and is homeless. The case note outlines her medical history and substance use as well as her mental health and living situation to inform her ongoing community care.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Reading Time: 5 minutes

    Writing Time: 40 minutes


    Read the case note and complete the writing task which follows.

    Ms. Amy Vineyard is a patient in your care at the St Kilda Women’s Refuge Centre. She is 6 weeks
    pregnant with her first child. She presented two days ago, requesting help for her substance
    abuse problems. She reports a desire to reduce or cease her alcohol consumption and a desire to
    reduce a cease her drug use. No desire has been indicated to decrease or stop cigarette use. She
    now wishes to be discharged but will require ongoing support throughout her pregnancy.

    Ms. Amy Vineyard


    21
    6/1/09
    Pregnant substance abuse
    8/1/09
    • Community mental Health Nursing required daily next 2 weeks
    minimum.
    • Pt wishes to continue living with a friend on her sofa.
    • Psychiatric support needed for depression.
    • Methadone program Alcoholics Anonymous meetings
    • 1 Trimester Ultrasound at 2 weeks;
    • maternal health clinic appointment needed.
    • Pt. self-admitted due to concern about pregnancy. Confirmed
    pregnancy test the days before (5/1/09)
    • Reported pain in lower back
    • weight loss (6kg over 2 months)
    • some memory loss
    • tingling in feet, difficulty sleeping, excessive worry and hallucinations
    • feeling depressed-history of depression
    • no pain in hips or joints
    • no decrease in appetite
    • no double vision
    • pt. monitored and blood tests for HIV/AIDS and STDs
    • counseled re nutrition and pregnancy
    • counseled re HIV/AIDS and STDs risk
    • discussed possibility of rehabilitation clinic for ‘driving out’
    • Nicotine daily 30-40 cigarettes
    • started smoking at 15 y. o.
    • Drugs used cannabis, amphetamines, cocaine, heroin
    • started all above at 16 y. o.
    • injects heroin, occasionally shares infecting equipment
    • Alcohol 8 units/day __ max. units/day- 15
    • started drinking at 16 y. o.
    • lives with a friend, Sophie, on her sofa.
    • no contact with parents
    • suicidal thoughts, self-harm in past
    • never seen a psychiatrist

    Using the notes, write a letter about Ms. Vineyard’s situation and history to new community
    health nurse. Address your letter to Ms. Lucy 8an, Registered Nurse, Community Health Centre,
    St Kilda.

    • Expand the relevant case notes into complete sentences


    • Do not use note form
    • Use letter format (Body of the letter should be approximately 180 – 200 words.)

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