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Case Notes 49.1

Case Notes 49.1 Mrs. Lisa Anderson (Nursing)

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:

You are Emily Ryan, Charge Nurse in the Emergency Department, Hills Hospital, Melbourne.

Today’s date: 25 July, 2024

  • Patient Details: Name: Mrs. Lisa Anderson.
  • Age: 34 years.
  • Address: 1212 River Side, 12th Avenue, Melbourne.

Presenting Complaints:

  • Severe fatigue. Shortness of breath. Swelling in legs and feet.
  • Persistent cough. Palpitations.
  • Diagnosis: Heart failure (exacerbated post-delivery).
  • Persisting Postpartum depression.

History:

  • Pregnancy and Delivery: G2-P2-L2. Delivered her second child three months ago via emergency C-section due to fetal distress.
  • Hypertension: Since 2020.
  • Gestational diabetes (during both pregnancies).
  • History of pre-eclampsia in first pregnancy.

07 July, 2024

  • Visited GP at Hills Hospital.
  • Diagnosed with postpartum depression.
  • Prescribed sertraline 50 mg daily.
  • Review on 24th July, 2024.

25 July, 2024 (11.30 AM)

  • Re-admitted to Hills Hospital with symptoms of heart failure.
  • Echocardiogram showed reduced ejection fraction (30%).
  • Commenced diuretics, ACE inhibitors, and beta-blockers.

Family History:

  • Mother has hypertension and type 2 diabetes.
  • Father died of myocardial infarction at 60 years old.

Social History:

  • Lives alone with her two children.
  • Husband deceased (died in a car accident a year ago).
  • No close family support.
  • Unemployed, financial difficulties.
  • Non-smoker, occasional alcohol use.

Medications:

  • Furosemide 40mg daily. Lisinopril 10mg daily.
  • Metoprolol 25mg twice daily. Sertraline 50mg daily

Physical Examination:

  • BP: 150/90 mmHg. HR: 110 bpm. RR: 22 breaths/min. SpO2: 94% on room air.
  • Weight: 80 kg. Height: 165 cm. BMI: 29.4

Investigations:

  • Blood tests: Elevated BNP levels, mild anemia (Hb: 10 g/dL).
  • Chest X-ray: Pulmonary congestion.
  • Echocardiogram: Reduced ejection fraction (30%).

03.00 PM (Today)

  • Discussed transfer to Green Valley Hospital.
  • Dr Lao S’Orvel agrees to see the patient tomorrow, 10.00 AM.

Plan:

  • Urgent referral to cardiologist for further management of heart failure.
  • Referral to social services for support.
  • Ongoing psychiatric support for postpartum depression.

Writing Task:

Using the information in the case notes, write a referral letter to Dr. Lao S’Orvel, Consultant Cardiologist, Green Valley Cardiology Hospital, Melbourne, requesting an urgent consultation for further assessment and management.

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.

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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