Day 11 Case Notes Analysis

This case notes will be used for writing today’s letters for correction. Before you proceed to writing this letter on the writing page, please read this case notes and answer the questions that below:



Read the case notes below and complete the writing task which follows.


You are the school nurse at a Toohey Point Primary State School

Today’s Date 27/11/2020

Patient Details

  • Alison Cooper, 10 years
  • Year 5 student
  • Height:138 cm; weight:40 kg
  • Eczema outbreaks on hands and mild asthma – has Ventolin inhaler
  • No other significant illnesses
  • Youngest in her class

Social History

  • Father died in motor accident 18 months ago.
  • Lives with mother, a bank manager, working full time
  • Middle child (Brother Simon, 7 and sister, Lisa, 12)
  • Paternal grandmother lives near school – provides after school and holiday care – looks after children if unwell

School Medical Record

Regular absences from school dating back to time of father’s death

  • Year 2 – 3 days
  • Year 3 – 4 days
  • Year 4 – 10 days
  • Year 5 – 8 days in first term

School Health Centre Records


  • February 8: Complained of headache. Gave paracetamol, rested and returned to class. Noted eczema on hands red and weepy – has ointment at home.
  • February 16: Complained of stomach ache. Called grandmother for pick up.
  • February 22: Complained of aching legs. Called grandmother for pick up.
  • March 4: Complained of headache. Gave paracetamol, rested 1 hour, still had headache. Called grandmother for pickup.
  • March 6: Feeling nauseous – eczema on hands red and weepy. Called grandmother for pick up.


  • February 15: Complained of toothache. Called grandmother for pick up.
  • April 4: Complained of headache. Gave paracetamol – rested 1 hour.
  • May 14: Headache, eczema on hands red and weepy, rested 1 hour not better called grandmother for pick up.
  • July 25: Feeling nauseous. Called grandmother for pick up.
  • August 16: Slight fever. Called grandmother for pick-up.
  • September 22: Feeling unwell. Eczema irritating. Called grandmother for pick up.
  • October 23: Complained of stomach ache. Rested 1 hour, returned to class.
  • November 27: Complained of headache. Gave paracetamol, rested 30 minutes.

Social History

Alison started school well – since Grade 3 trouble concentrating – rarely participates class activities (unless encouraged). Avoids sporting activities – standard of school work declining. Few friends – often teased (classmates). Embarrassed about hands (don’t seem to be responding well to ointment suggested by chemist). Mother was contacted by class teacher regarding these issues. Says Alison is also becoming withdrawn at home. Alison was very close to her father – often talks to her about him and cries because she misses him. (Doesn’t like the fact that mother has a boyfriend at present. Says, “will kill myself if papa is replaced.”) Seeks comfort in food like chips and cakes after school.


Refer her to the school psychologist to find out whether Alison has underlying grief related or other psychological problems. (Should be accompanied by mother)

Writing Task

Using the information in the case notes, write a letter to refer this girl to the school psychologist, Barnaby Webster, to assess her. Outline the purpose of the referral. Provide details of significant factors which will assist the psychologist to make this assessment.

In your answer:

  • Expand the relevant notes into complete sentences
  • Do not use note form
  • Use letter format
  • The body of the letter should be approximately 180–200 words.

Now take this Case Notes Analysis and proceed to Letter Writing

  • Question of

    Who is the patient?

    • A five year old girl child with physical and psychological discomfort
    • A ten year old child with physical and psychological discomfort
    • A 11 year old child with physical and psychological discomfort
  • Question of

    Who is the recipient of this letter?

    • Psychiatrist
    • Psychologist
    • School Nurse
  • Question of

    What is the purpose of this letter?

    • Requesting treatment
    • Requesting assessment
    • Requesting admission
  • Question of

    What is troubling the patient?

    • Father’s death
    • Eczema
    • Both
  • Question of

    What is the admission / discharge status?

    • Admitted (School)
    • Not admitted (School)
    • Discharged (School)
  • Question of

    What is the least relevant information?

    • Social
    • Detailed school health centre records
    • Behavior
  • Question of

    Should Alison’s mother be considered as a patient?

    • Yes, as the psychologist is concerned.
    • No

Written by Biju John

Love for English begins with understanding its unknown rules. Biju John lives on the internet, teaching OET, IELTS and PTE. More than a million students have thanked him from their heart.

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One Comment

  1. 27 November,2020

    Ms Barnaby Webster
    School Psychologist

    Dear Ms Webster,

    I am writing to refer Alison, a 5 th grade student, who requires further psychological assessment and management.She is suspected to have underlying grief following her father’s unexpected death.

    Alison is the middle child among her two siblings.She lives with her mother,who works as a bank manager.Due to Alison’s mother’s busy work,her paternal grandmother is providing after school and holiday care and looks after her siblings also, especially if they are ill.Medically,Alison has eczema outbreaks on her hands and uses inhaler for asthma attacks.

    Alison was a bright student until grade 3.She has been regularly absent from school after her father’s demise. Since then she rarely participates in school activities including sporting events.She has always been teased of her eczema flare-ups by her classmates and often feels embarrassed about her skin condition.

    Due to Alison’s declining standard in her studies, her mother was contacted and discussed regarding these current issues.Her mother also reported about her withdrawn nature at home.As per her mother, Alison was so close to his father and cannot accept her father’s loss.As a result,she often find comfort in eating oily and fatty foods after school.Currently,her height is 138 cm and weighs 40 kg.

    Considering the above information,please take over the care of this young student and provide necessary support.

    Please contact me for any queries.

    Yours sincerely,

    School Nurse

Day 10 Speaking Tasks

Day 12 Case Notes Analysis