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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.

  • Question of

    Is this a known case?

    • Yes
    • No
    • It is a partially known case.

    Correct Wrong

    It is a partially known case because an appointment has been arranged with the recipient. When an appointment is arranged, part of the patient details are provided.

  • Question of

    Who is the recipient of this letter?

    • A Pediatrician in Brisbane.
    • A Pediatric Nurse in Sydney.
    • A Pediatrician in Sydeny.

    Correct Wrong

  • Question of

    Is the patient being transferred or discharged?

    • Being transferred today.
    • Ready for discharge.
    • Being discharged today.
    • Ready for transfer.

    Correct Wrong

    When you say "Ready," the recipient cannot understand "when." When you say "Being" discharged or transferred, the recipient understands it more clearly. "Being" means "now."

  • Question of

    What is the purpose of writing this letter?

    • Further assessment.
    • Further care.
    • Monitoring of symptoms.

    Correct Wrong

    All assessments are done. The baby has GERD, and that's clear. So, what the baby needs is not assessment but monitoring for recurrence / symptoms.

  • Question of

    What is / are the baby’s present clinical complaints?

    • No complaints.
    • Recurrence of previous conditions.
    • Stable with mild presence of GERD and COPD.

    Correct Wrong

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Reading 36B1

Grammar 3