Case Notes 39.1

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: 11/07/2024. This patient, who has been under your care since admission, wishes to get a discharge soon as she wishes to live with her eldest daughter in Canberra and get treated by a Respiratory specialist she knows.

• Patient Name: Emma Watson.
• DOB: 15/04/1962
• Address: 45 Green Street, Brisbane.
• Marital Status: Married

Medical History:

• Hypertension (diagnosed 2010)
• Type 2 Diabetes (diagnosed 2015)
• Asthma (diagnosed 2000)
• Appendectomy (2018)
• Allergies: Penicillin

Social History:

• Occupation: School Teacher
• Smoker: No
• Alcohol: Occasional (1-2 drinks per week)
• Exercise: Regular (3 times a week)
• Support System: Husband and two daughters (the eldest, Mona Freeman lives in Canberra but visits her parents every week).

Current Medications:

• Metformin 500mg BD
• Ramipril 5mg OD
• Salbutamol Inhaler PRN

08/07/2024

• Acute exacerbation of asthma.
• Shortness of breath (onset 3 days ago).
• Wheezing; Tightness in the chest.
• Persistent cough.
• Expresses her wish to be taken care of by her son (respiratory specialist in another hospital).

Examination Findings:

• BP: 150/95 mmHg; HR: 98 bpm
• RR: 24 breaths/min; SpO2: 92% on room air
• Peak Flow: 250 L/min.

Treatment Provided:

• Oxygen therapy (4 L/min via nasal cannula)
• Nebulized Salbutamol (2.5 mg) and Ipratropium Bromide (0.5 mg)
• Prednisolone 40 mg PO
• IV Fluids (Normal Saline).

Nursing Management:

• Oxygen therapy initiated (4 L/min via nasal cannula)
• Administered nebulized Salbutamol (2.5 mg) and Ipratropium Bromide (0.5 mg)
• Administered Prednisolone 40 mg PO
• Provided IV Fluids (Normal Saline)
• Monitored vital signs (every 2 hours).
• Conducted peak flow measurements every 4 hours
• Maintained oxygen therapy as prescribed
• Encouraged fluid intake
• Educated patient on asthma management and medication use.
• Arranged transfer to another hospital where her son works.

Discharge Plan:

• Allow the patient to be seen and treated by her son.
• Prescribe a short course of oral corticosteroids (Prednisolone 40 mg for 5 days).
• Ensure patient has an asthma action plan.
• Refer to asthma educator for further education.
• Special request: Arrange a new GP at Doctor Hospital (current GP is retiring soon).
• Transfer all medical records to Doctor Hospital within 2 working days.

Writing Task

Ms Watson’s GP has decided that she be transferred to Doctor Hospital, Silent Valley, Canberra where her son, a respiratory specialist, works. Using the case notes, write a letter to Dr Arthur Freeman Watson, for further management. Address the letter to Doctor Hospital, Kent St, Canberra 2600, Australia.

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. Do not pick your pencil during the 5 minutes of reading time.