Case Notes 02

Case Notes 02 – Krit Palmer (Nursing)

Occupational English Test – Writing (Nursing)

Instructions:

• You have 45 minutes to write this letter.
• During the first 5 minutes, you should not pick the pencil.
• Start writing only when you are told.
• During the Reading Time, try to understand the case notes.

Melons Steps

• Mark (M) PPRRAADDDDDWK.
• Eliminate (E) irrelevant information.
• Launch (L) the letter with DADR.
• Open (O) the letter with PRPDD or PRPTT.
• Narrate (N) the remaining paragraphs using V or W.
• Sign (S) the letter with S/F.

Melons Errors

• Punctuation “Marks”.
• Follow “Expansion” Rules.
• Obey “Language” Rules.
• Have an “Order” (DADR, PRPDD, V/W, S/F)
• Do not change “Names”.
• Sex (Mr, Ms, Mrs, His, Her).

Details to Fill In:

• CANDIDATE NAME. ROLE NUMBER.
• DATE OF BIRTH. VENUE OF THE TEST. TEST DATE.

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

Notes:

Imagine today’s date is 24/07/2024. Ms Jane and her new born have visited your clinic for a follow up and concerns over the baby’s health and coping.

Patient Details:

• Baby Krit Palmer
• Age: 1 month
• Date of Birth: June 24, 2024 (preterm, born at 34 weeks gestation).
• Gender: Male.
• Mother: Jane Palmer.
• Address: 123 Elm Street, Cityville.
• Contact Number: 01234 567890.

Medical History (Mother):

• G2P1 (Gravida 2, Para 1)
• No known allergies.
• History of mild gestational diabetes, managed with diet.
• No significant past medical history.
• Current medication: Prenatal vitamins, Iron supplements

Krit’s Health:

• Born preterm at 34 weeks gestation.
• Apgar score: 8 at 1 minute, 9 at 5 minutes.
• Required NICU stay for 2 weeks for respiratory support (CPAP) and monitoring.
• No major congenital anomalies detected.
• Current weight: 2.5 kg (birth weight: 2.0 kg).
• Feeding: Breastfed, supplemented with formula.
• Vaccinations: BCG, Hepatitis B (birth dose).
• Current medications: Multivitamin drops, Iron supplements.

Family History:

• No significant family history of genetic disorders or chronic illnesses.
• Both parents are healthy and have no known hereditary conditions.

Social History:

• Non-smoker.
• Occasional alcohol consumption before pregnancy, abstained during pregnancy.
• Married, living with husband and parents.
• Supportive family environment.
• Mother on maternity leave, primary caregiver of the baby.
• Husband is employed full-time, but provides support after work hours.

Presenting Complaint:

• Baby Krit is feeding well but seems to be fussy and crying more than usual.
• Slight jaundice noticed in the baby.
• Mother experiencing fatigue and mild breast discomfort.

Examination Findings (Baby)

• Alert, active, mildly jaundiced
• Temperature 36.8°C, HR 140 bpm, RR 40 bpm.
• Weight: 2.5 kg.
• Head-to-toe examination: No significant abnormalities, mild jaundice (noted on sclera and face).
• Feeding: Sucking well during breastfeeding, supplementing with formula.
• Stool and urine output: Normal.

Mother

• Tired but well, no signs of distress.
• Breast examination: No signs of mastitis, mild engorgement, good latch during breastfeeding

Management

• Discussed signs of severe jaundice and when to seek immediate medical attention.
• Provided contact information for lactation support services.
• Encouraged the mother to reach out if she has any concerns or notices any changes in the baby’s condition.

Plan

• Monitor jaundice levels: Perform a bilirubin check.
• Continue breastfeeding and supplementing with formula.
• Ensure adequate hydration and feeding.
• Follow-up appointment in 1 week to reassess jaundice and overall growth.
• Advise on signs of worsening jaundice or feeding difficulties.
• Encourage rest and adequate hydration (mother).
• Educate on breastfeeding techniques and management of engorgement.
• Provide support and resources for postpartum care.
• Bilirubin check.
• Arrange daily visits by a community nurse for 1 week for monitoring the baby and the mother.

Writing Task:

Using the information in the case notes, write a letter of referral to Ms Sarah Smith, Community Nurse, 456 Oak Street, Cityville, NSW 2000, Australia for further monitoring.

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.