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.