OET Writing Space — English Melon

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.