OET Case Notes 1 – Nursing

Sample Letter

13 May, 2023

Ms Susan Parry
Admitting Nurse
Helping Hand Rehabilitation Centre
Eagle Vale, Sydney, NSW, Australia

Dear Ms Parry,

Re: Ms Nina Davies; DOB: 25 December, 1949

Thank you for accepting the care of Ms Nina Davies who requires continuing care and management. She is recuperating after left hemiarthroplasty. She is ready for transfer.

Ms Davies was admitted on 09 May, 2023 with (7) ____ (the injury / injury / an injury) on (8) ____ (the / x) left hip (9) _______________ (following / followed by) a fall and (10) _____ (was undergone / undergone / underwent) the surgery on the same day. Postoperatively, she (11) ____ (was experienced / experienced) (12) _____ (restless / restlessness) and confusion which was treated (13) _____ (by / with) antibiotics, analgesics and antidiuretics and later on, stopped due to hypotension. On subsequent days, (14) _________ (she was initiated physiotherapy / physiotherapy was initiated) which (15) ____ (need / needs) to be continued.

Ms Davies has mild hyperlipidaemia, hypertension, coronary artery disease, tendonitis of the right shoulder for which) she is on regular medication.

In view of the present condition, it would be appreciated if you could arrange assistance. Please note that her staples need to be removed on the 14th day and ensure that the dressing remains dry and intact. A detailed list of her current medication is attached herewith.

You may contact me if you have any queries information.

Yours sincerely,

Mr Philips Jones,

Charge Nurse.

Case Notes

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.

14 Case Notes (Melons)