OET Writing Space — Ente English

Case Notes 1 — Brendan Cross

Notes

Today's Date: 14/3/2024.
The following patient has been under the care of Paediatrician Dr Nancy Rose at the hospital where you are his charge nurse.

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.

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 25 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.

12/3/2024 — Objective

Temperature 39.2° C.
Hypertrophied tonsils.
Cervical lymph node – NL.
Swollen R. knee joint. No effusion.
Mid systolic murmur, RR normal.

Investigation & Treatment

ECG, FBC, ASOT ordered.
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.
Expand the relevant case notes into complete sentences. Do not use note form. Use the correct letter format.
The body of your letter should be approximately 200 words.

You are writing the 1. Date

Press the ◀ left arrow to read your Case Notes.

ERRORS: 0WORDS: 0SCORE: 400

MELONS Steps

1. Date
Write today's date (as given in the case notes) on line 1. Use the order Day Month Year, with the month and year written in full.
17 August, 2026
2. Recipient address
Leave a blank line, then write the recipient block: name, designation, hospital or organisation, street, and town/postcode — one item per line, no blank lines inside.
Ms Samantha Bruin Senior Nurse Greywalls Community Nursing Services 27 Station Road Greywalls - 55
3. Salutation
Leave a blank line, then greet the reader. Use "Dear" + name when the name is given (e.g. "Dear Ms Bruin,"). End with a comma.
Dear Ms Bruin,
4. Re: line
Write the "Re:" line with the correct prefix (Baby, Miss, Master, Mr, Ms, Mrs), the patient's full name and age.
Re: Mr Gerald Baker; 79 years
5. Opening paragraph
State who the patient is, why you are writing and what you want the reader to do (PRPPD: Patient, Reason, Purpose, Plan, Diagnosis). Keep it to 2–3 sentences.
Mr Gerald Baker requires continued care back at your facility. He is recuperating after a hip replacement surgery and is ready to be discharged tomorrow.
6. Body 1 — admission & recent history
Describe the admission and what happened during it. Use the past tense.
Mr Baker was admitted on 25 February, 2024 and underwent surgery on the next day. During postoperative recovery he had disorientation regarding time and place.
7. Body 2 — current condition & medication
Describe the present condition, current medication and treatment. Use the present tense.
At present, Mr Baker is on Aspirin, 100 mg and Ramipril, 5 mg, both in the morning. He is receiving daily dressings along with strengthening exercises.
8. Body 3 — past history / background
Add relevant past medical history or lifestyle, occupation, nutrition and social details (LONS).
Mr Baker is a widower of eight years and has been living at your nursing home for four years. He has been managing hypertension since 1991.
9. Requests & closing paragraph
State clearly what care you are requesting, then offer further contact.
His staples need to be removed before 15 March. For any further information about Mr Baker, kindly contact me.
10. Signing off
Use "Yours sincerely," when you addressed the reader by name, or "Yours faithfully," when you wrote Dear Sir/Madam/Doctor. Leave a blank line, then your role.
Yours sincerely, Charge Nurse