Case Notes 20.5 Peter Ludvik

Case Notes 20.5 Peter Ludvik

TIME ALLOWED:

READING TIME: 5 MINUTES
WRITING TIME: 40 MINUTES

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

Today’s Date: 10/09/2023

Notes:

The following patient has been presenting to Hope Child and Mother Care, Springvale, Melbourne, where you have been Charge Nurse.

• Patient: Peter Ludvik, 8 years old

12/08/2023

• Complains of sore throat. Mother reports fever, irritable.
• Voice hoarse

O/E:

• Enlarged tonsils, exudate
• Tender, large cervical nodes
• T 39.5°
• Assessment: Tonsillitis
• Plan: Penicillin v 250 mg qid 7 days

7/09/2023

• Ludvik reported son’s urine brown 4 days previously.
• Says Peter is lethargic, no report of frequency, trauma or dysuria.
• O/E: tonsillar hypertrophy
• BP 90/60
• Urinalysis – macroscopic haematuria
• Assessment:
• ? post streptococcal nephritis
• ? urinary tract infection

Plan:

• R/V 2 days
• Fluids, rest

Tests:

• Full Blood Examination (FBE), urea and creatinine;
• [U&E], electrolytes, mid-stream urine [MSU]
• Micro/culture/sensitivity [M/C/S], Antistreptolysin-O Titre [ASOT] and cell morphology

10/09/2023

• Peter asymptomatic
• O/E: BP 110/90
• Macroscopic haematuria

Test results:

• FBE normal
• U&E↑
• ASOT↑+++
• MSU – 4X 10 # RBC of renal origin

Assessment:

• Post streptococcal nephritis with early renal failure
• Plan: Refer to paediatrician

WRITING TASK

Using the information in the case notes, write a letter of referral to Dr Xavier Flannery, a paediatrician at 567 Church St Springvale 3171.

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.