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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.

  • Question of

    Who is the recipient?

    • A new GP
    • A respiratory specialist in the same hospital.
    • A respiratory specialist in another hospital.
  • Question of

    Is this a known case?

    • Yes
    • No
  • Question of

    Is the patient’s condition diagnosed?

    • Yes
    • No
    • Partially.
  • Question of

    Is the patient on medication for the current condition?

    • Yes
    • No
  • Question of

    What is the patient’s current medical condition (P3)?

    • Diagnosed.
    • Treatment provided.
    • Recuperating.
    • No notable progress.
  • Question of

    What is the purpose of this letter?

    • Further care and management.
    • Diagnose the patient.
    • Advice.

What do you think?

Written by englishmelon

Get in touch with us to prepare for English examinations of any kind. We teach OET, IELTS, PTE, IB and CBSE. We use simple tricks to learn and memorize complex structures for Reading, Listening, Writing and Speaking. Our Personal Trainers are quite down to the earth and well experienced.

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