Case Notes 52.1 “Fransca De Bird”

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).

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

Notes:

Imagine that today is 30 July, 2024 and you are a nurse working at a Clinic where this patient was brought 2 hours ago.

Patient Details:

• Name: Fransca De Bird.
• Date of Birth: 10/02/1923 (101 years).
• Gender: Female

Social History:

• Resides in a joint family with children and grandchildren.
• Marital Status: Widow (since 1996).
• Three sons and two daughters, all live interstate.
• Grandchildren: Eight.
• Great-Grandchildren: Twenty-nine.
• Non-smoker.
• Alcohol: Rare social drinker.

Medical History:

• Previous Conditions: Hypertension, Osteoarthritis, Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF).
• Hospital Admissions: Mostly in her eighties; reluctant to be hospitalized.
• Monocular vision (left eye, since the age of 56).
• Appendectomy at age 45, Hip replacement at age 85.
• Right shoulder pain since she was in her early forties. Managed with diclofenac ointments.

Recently commenced Medication:

• Amlodipine 5 mg daily.
• Paracetamol 500 mg as needed for pain.
• Salbutamol inhaler as needed.
• Furosemide 20 mg daily.
• Allergies: None known.

Presenting Complaint:

• Brought by two grandchildren at 06.10 AM.
• Breathing difficulty since last night.
• Onset: Sudden.
• Current Status: Symptoms persist.
• Reports backpain. Nausea.
• Diagnosis: Nil.

Vital Signs:

• Blood Pressure: 130/70 mmHg
• Heart Rate: 90 bpm
• Respiratory Rate: 24 breaths per minute
• Temperature: 36.8°C
• Oxygen Saturation: 92% on room air

Physical Examination:

• General: Alert and oriented, appears slightly anxious.
• Respiratory: Mild wheezing, decreased breath sounds bilaterally.
• Cardiovascular: No murmurs, regular rhythm.
• Abdomen: Soft, non-tender, no masses.
• Extremities: No edema.

Plan:

• Transfer to Emergency Doctor for further evaluation and management.
• Administer oxygen therapy to maintain oxygen saturation on arrival.
• Vital signs will be monitored during transfer (expected arrival in Caring Cross at 08.45 AM).
• Prepare for possible nebulizer treatment.
• Ensure patient records and medication list are transferred with the patient.

Writing Task

Using the information in the case notes, write a letter of referral to the Emergency Doctor at Caring Cross Hospital, Sydney to admit the patient and provide immediate care.

In your answer:

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

The body of your letter should be approximately 200 words. Use correct letter format.