Occupational English Test – Writing case Notes | Medicine
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.
Read the case notes below and complete the writing task which follows.
Notes:
Patient Details
- Aarav Joseph
- Age: 6 months
- Gender: Male
- Mother’s Name: Mrs. Neha Joseph
- Age: 28 years
- Address: 42/B, Lakeview Apartments, Kochi
Medical History (Baby – Aarav Joseph)
- Full-term normal vaginal delivery
- Birth weight: 3.2 kg
- Immunizations: Up to date
- No previous hospital admissions
- Feeding: Breastfed + occasional formula
Presenting Complaint (15 June 2025)
- Fever (38.7°C) for 2 days
- Refusal to feed
- Irritability
- Mild cough, nasal congestion
- Decreased wet nappies
Examination Findings
- Temperature: 38.7°C
- HR: 140 bpm
- RR: 44/min
- Chest: Mild crepitations (L lower zone)
- Throat: Red, no pus
- Ears: Normal
- Weight: 6.9 kg
Diagnosis
- Likely viral upper respiratory tract infection (URTI)
- Mild dehydration
Treatment Given (16 June 2025)
- Oral Paracetamol 5 ml (every 6 hrs)
- ORS (oral rehydration salts) encouraged
- Nasal saline drops
- Breastfeeding encouraged
- Observation for 24 hrs
- Education given to mother: signs of dehydration, fever control, red flag signs
Plan / Recommendations
- Recheck if fever persists > 3 days
- Increase fluid intake
- Monitor urine output
- Follow-up with GP in 3 days or earlier if condition worsens
Writing Task
Using the information in the case notes, write a letter to Dr. Radhika Nair, the family physician of the baby and mother, at Lotus Family Clinic, 12 Market Road, Melbourne. In your letter, update her on the baby’s recent illness and the treatment given, and request follow-up care. Address the letter to Dr. Radhika Nair.
- Do not use note form.
- Main content: Around 200 words
