Case Notes 38.1

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:

Today’s Date: 10/07/2024

This 50-year-old, school teacher, got admitted to your hospital 20 hours ago and you are her charge nurse at a suburban hospital in Burche, 20 miles North of Wickham Terrace.

Patient Details:

• Micah Hastings (Mrs).
• DOB: 04/05/1974 (50 years)
• 2321 Mosque Road, 2 Rolls, Brisbane.
• School Teacher, lives with husband and two sons (21 and 15).
• Lifestyle: Non-smoker, occasional alcohol use.
• Family History: Father – Hypertension; Mother – Diabetes.

Medical History

• Hypertension, Asthma since the age of 30.
• Atenolol 50 mg OD; Salbutamol Inhaler PRN.
• Allergies: Penicillin.

08/07/2024

• Fall, possible concussion.
• Headache, confusion, lack of coordination, memory loss, nausea, vomiting, dizziness, ringing in ears, sleepiness, excessive fatigue, seizures.
• Admitted to the Casualty.
• Initial Dx: Concussion.
• IV fluids; Paracetamol 1g q6h for pain; Ondansetron 4mg q8h for nausea.
• Commenced monitoring for neurological symptoms.
• Shifted to a room for further management.

July 9, 2024

• Symptoms worsening.
• Planned transfer to Wickham but doctors uncertain about the transfer due to adverse weather changes (landslides in the valley between Burche and Wickham).
• Increased headache. Persistent confusion. Coordination issues.
• Seizure episodes. Blood detected in saliva (at midnight).

10/07/2024 07.00 AM

• Patient being transferred to Trauma Centre.

Plan

• Transfer to Trauma Centre, Wickham Terrace.
• Further assessment and management.
• IV fluids, Paracetamol 1g q6h, Ondansetron 4mg q8h (Continue on transfer).

Writing Task

Since her admission 20 hours ago, Mrs Hastings’ condition has been worsening. You are now transferring the patient to a trauma centre in Wickham for further assessment and management. Address the letter to the Emergency Admission Desk, Trauma Centre, 2/201 Wickham Terrace, Spring Hill QLD 4000, Australia. Phone: +61 1300 087 281.

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.