Case Notes 37.1 Baby Liam Johnson

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 that today’s date is July 9, 2024, and you are a nurse at Mount Carmel Hospital, Brisbane, discharging a patient today after a week’s stay.

Patient Details:

• Baby Liam Treasure.
• Date of Birth: January 7, 2024 (6 months old).
• 456 Oak Street, Brisbane, QLD 4000.
• Father and mother: Army Officers.
• Father William Treasure, posted at Sydney a week ago.

Medical History:

• Born prematurely at 32 weeks gestation.
• January 2024: Diagnosed with Respiratory Distress Syndrome (RDS).
• March 2024: Diagnosed with gastroesophageal reflux disease (GERD).
• May 2024: Respiratory syncytial virus (RSV) infection, hospitalized for 10 days.

July 1, 2024:

• Admitted: Mount Carmel Hospital. Severe vomiting, dehydration.
• Initial Dx: Gastroenteritis.
• Treatment: IV fluids, Ondansetron 2 mg q8h, monitoring electrolyte levels.

July 2, 2024:

• Fever (38.5°C), lethargy.
• Blood cultures, started Ceftriaxone 100 mg/kg/day IV.

July 3, 2024:

• Blood culture results: Positive for E. coli.
• Continued Ceftriaxone, monitoring for sepsis signs.

July 5, 2024:

• Fever resolved, condition improving.
• Gradual reintroduction of oral feeds.

July 7, 2024:

• Stable vital signs but mild GERD and COPD.
• Tolerating feeds well.
• Family relocating to Sydney (Patient’s mother being transferred to Army Headquarters, Sydney)
• Plan for discharge initiated, with follow-up arranged at Sydney Children’s Clinic.
• Appointment date: 15 July, 2024.

July 9, 2024:

• Ready for discharge.
• Ondansetron 2 mg q8h PRN for nausea, Amoxicillin 125 mg q12h for 7 days.
• Follow-up with Pediatrician deferred. New date: 16 July, 2024.
• Parents educated on signs of dehydration, proper feeding techniques, medication administration.

Plan:

• Discharge today with instructions.
• Follow up with new Pediatrician.
• Ensure follow-up care and monitor for recurrence of GERD or other conditions the baby had earlier (COPD).

Writing Task:

Using the information in the case notes, write a letter to the patient’s new Pediatrician prior to the scheduled follow-up care after discharge. Address the letter to Dr. Rebecca Thompson, Sydney Children’s Clinic, 789 George Street, Sydney, NSW 2000.

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.