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Case Notes 2.1 Sally McConville

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Case Notes 2.1 Sally McConville

Occupational English Test

Writing: Nursing

Reading Time: 5 Minutes. Should not write during this time.
Writing Time: 40 Minutes


You are a nurse in charge of the patient who has been visiting your clinic for the past couple of days.

Today’s Date: 18/09/2023

  • Patient: Sally McConville (Ms), aged 38
  • Occupation: Administrator
  • Marital Status: Single

Past History:

  • Asthma, hypertension, cholecystectomy, ankle fracture, depression, non-smoker till 35 years.


  • Ramipril 2.5 mg daily,
  • Paroxetine, 20 mg daily,
  • Fluticasone 250-2 puffs daily,
  • Ventolin (salbutamol), 2 puffs PRN
  • Allergies: Nil


  • 2-day history of runny nose; cough productive of yellow sputum;
  • Slight fever; wheezy but not short of breath.
  • Asthma usually well-controlled on preventer (fluticasone 250-2 puffs daily)
  • Temperature 37.5; Pulse 82; BP 120/80, RR 12; Obvious nasal congestion; Throat red; Ears normal;
  • No increased work of breathing, no accessory muscle use, chest scattered wheeze, no crepitations.


  • Viral upper respiratory tract infection.
  • Infective exacerbation of asthma.

Treatment ++

  • Ventolin 2 puffs 4-hrly, continue preventer
  • Medical certificate for work
  • Review as required


  • Increasing shortness of breath & wheeze over last 24hrs, feeling feverish at times, minimal yellowy sputum, short of breath on minimal exertion.
  • Examination: Temperature 38, pulse 95, BP 120/80, respiratory rate 16, throat red, ears normal, mildly increased work of breathing, chest-widespread wheeze, no crepitations.
  • Assessment: Infective exacerbation of asthma- symptoms worse.
  • Treatment: Amoxicillin 500 mg 3 x daily, prednisolone 25 mg daily x 3 days Continue 4-hourly Ventolin & preventer.


10.30 am

  • ↑Short of breath today despite prednisolone & antibiotics.
  • Feeling feverish & unwell.
  • Examination: Short of breath at rest, respiratory rate 25, obvious accessory muscle use & increased work of breathing, pulse 112, BP 100/65, temp 37.7, chest exam- widespread wheeze, binasal crepitations
  • Assessment: Acute asthma, ? Pneumonia.
  • Treatment: Ventolin Nebules (salbutamol) 5mg, review.

10.45 am

  • No improvement. Still obvious respiratory distress.
  • Refer to Emergency Department for acute management & investigation
  • ? Pneumonia

Writing Task

Using the information given in the case notes, write a letter of referral to the Admitting Officer at the Emergency Department, Newtown Hospital.

In your answer:

  • Expand the relevant notes into complete sentences.
  • Do not use note form.
  • Use letter format.

Your letter should have a word count of 180 – 200 hundred words. However, the numbers can go up or down depending on the relevance of information.

What do you think?

Written by English Melon

Biju John, author of ByeBle and Maclins, is an English Language Trainer. He has also authored his educational Fiction. All these titles are available on Amazon and Google. You can contact his office on WhatsApp / Telegram number +917510923061

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IELTS Writing with Melons Methods

Mention Practice – Series I