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.
