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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.

What do you think?

Written by englishmelon

Get in touch with us to prepare for English examinations of any kind. We teach OET, IELTS, PTE, IB and CBSE. We use simple tricks to learn and memorize complex structures for Reading, Listening, Writing and Speaking. Our Personal Trainers are quite down to the earth and well experienced.

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