Case Notes 2

Occupational English Test – Writing (Nursing)

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

Notes:

The following patient has been under the care of Pediatrician Dr Nancy Rose at the hospital where you are his charge nurse.

Today’s Date 14/3/2024

Patient History

• Brendan Cross, Male, DOB: 25/12/2023.
• Has a sister 6 years, brother 3 years.
• Mother – housewife.
• Father – Naval Officer currently on active duty in Indonesia.
• P.M.H – NAD.
• Allergy to nuts – hospitalised with anaphylaxis 2 years ago following exposure to peanuts.

6/3/2024

• Subjective: Fever, sore throat, lethargy, many crying spells – all for 3 days.
• Objective: Temperature – 39.8° C; Enlarged tonsils with exudate; Enlarged cervical L.N.
• Ab – NL; CVS – NL; RR – NL.
• Probable Diagnosis: Tonsillitis (bacterial)

Management

• Oral Penicillin 250 mg 6/h, 7 days + Paracetamol as required.
• Review after 5 days if no improvement.

12/3/2024

Subjective

• Mother concerned re. sleepless nights, difficulty coping with husband away – mother-in-law coming to help.
• Brendan not eating. 
• Fever, right knee joint pain, tiredness, lethargy – for 2 days.

Objective

• Temperature – 39.2° C.
• Hypertrophied tonsils.
• Cervical limph node – NL.
• Swollen R. Knee Joint.
• No effusion
• Mid systolic murmur, RR – normal.
• Investigation
• ECG, FBC, ASOT ordered

Treatment

• Brufen 100 mg tds.
• Review in 2 days with investigation reports.

14/3/2024

• No change of symptoms.
• ECG – prolonged P-R interval.
• ESR – increased.
• ASOT – Increased.
• Diagnosis. ? Rheumatic fever.

Plan

• Contact Spirit Paediatric Centre.
• Arrange an urgent appointment with Dr Alison Grey, Senior Paediatric Consultant.
• Request further investigation and treatment.

Writing Task

You are a nurse at Green Slopes Medical Clinic, 294 Logan Rd, Green Slopes, Brisbane 4122. Write a referral letter to Dr Alison Grey, Spirit Paediatric Centre, Sixth Street, Brisbane 4101.

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 the correct letter format.