Case Notes 49.1

Case Notes 49.1 Mrs. Lisa Anderson (Nursing)

Occupational English Test – Writing (Nursing)

Instructions:

• You have 45 minutes to write this letter.
• During the first 5 minutes, you should not pick the pencil.
• Start writing only when you are told.
• During the Reading Time, try to understand the case notes.

Melons Steps

• Mark (M) PPRRAADDDDDWK.
• Eliminate (E) irrelevant information.
• Launch (L) the letter with DADR.
• Open (O) the letter with PRPDD or PRPTT.
• Narrate (N) the remaining paragraphs using V or W.
• Sign (S) the letter with S/F.

Melons Errors

• Punctuation “Marks”.
• Follow “Expansion” Rules.
• Obey “Language” Rules.
• Have an “Order” (DADR, PRPDD, V/W, S/F)
• Do not change “Names”.
• Sex (Mr, Ms, Mrs, His, Her).

Details to Fill In:

• CANDIDATE NAME. ROLE NUMBER.
• DATE OF BIRTH. VENUE OF THE TEST. TEST DATE.

Read the case notes below and complete the writing task which follows. 

Notes:

You are Emily Ryan, Charge Nurse in the Emergency Department, Hills Hospital, Melbourne.

Today’s date: 25 July, 2024

• Patient Details: Name: Mrs. Lisa Anderson.
• Age: 34 years.
• Address: 1212 River Side, 12th Avenue, Melbourne.

Presenting Complaints:

• Severe fatigue. Shortness of breath. Swelling in legs and feet.
• Persistent cough. Palpitations.
• Diagnosis: Heart failure (exacerbated post-delivery).
• Persisting Postpartum depression.

History:

• Pregnancy and Delivery: G2-P2-L2. Delivered her second child three months ago via emergency C-section due to fetal distress.
• Hypertension: Since 2020.
• Gestational diabetes (during both pregnancies).
• History of pre-eclampsia in first pregnancy.

07 July, 2024

• Visited GP at Hills Hospital.
• Diagnosed with postpartum depression.
• Prescribed sertraline 50 mg daily.
• Review on 24th July, 2024.

25 July, 2024 (11.30 AM)

• Re-admitted to Hills Hospital with symptoms of heart failure.
• Echocardiogram showed reduced ejection fraction (30%).
• Commenced diuretics, ACE inhibitors, and beta-blockers.

Family History:

• Mother has hypertension and type 2 diabetes.
• Father died of myocardial infarction at 60 years old.

Social History:

• Lives alone with her two children.
• Husband deceased (died in a car accident a year ago).
• No close family support.
• Unemployed, financial difficulties.
• Non-smoker, occasional alcohol use.

Medications:

• Furosemide 40mg daily. Lisinopril 10mg daily.
• Metoprolol 25mg twice daily. Sertraline 50mg daily

Physical Examination:

• BP: 150/90 mmHg. HR: 110 bpm. RR: 22 breaths/min. SpO2: 94% on room air.
• Weight: 80 kg. Height: 165 cm. BMI: 29.4

Investigations:

• Blood tests: Elevated BNP levels, mild anemia (Hb: 10 g/dL).
• Chest X-ray: Pulmonary congestion.
• Echocardiogram: Reduced ejection fraction (30%).

03.00 PM (Today)

• Discussed transfer to Green Valley Hospital.
• Dr Lao S’Orvel agrees to see the patient tomorrow, 10.00 AM.

Plan:

• Urgent referral to cardiologist for further management of heart failure.
• Referral to social services for support.
• Ongoing psychiatric support for postpartum depression.

Writing Task:

Using the information in the case notes, write a referral letter to Dr. Lao S’Orvel, Consultant Cardiologist, Green Valley Cardiology Hospital, Melbourne, requesting an urgent consultation for further assessment and management.

In your answer:

• Expand the relevant notes into complete sentences.
• Do not use note form.
• Use letter format.

The body of the letter should be approximately 180–200 words.