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Case Notes 52.1 “Fransca De Bird”

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).

Read the case notes below and complete the writing task which follows.

Notes:

Imagine that today is 30 July, 2024 and you are a nurse working at a Clinic where this patient was brought 2 hours ago.

Patient Details:

  • Name: Fransca De Bird.
  • Date of Birth: 10/02/1923 (101 years).
  • Gender: Female

Social History:

  • Resides in a joint family with children and grandchildren.
  • Marital Status: Widow (since 1996).
  • Three sons and two daughters, all live interstate.
  • Grandchildren: Eight.
  • Great-Grandchildren: Twenty-nine.
  • Non-smoker.
  • Alcohol: Rare social drinker.

Medical History:

  • Previous Conditions: Hypertension, Osteoarthritis, Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF).
  • Hospital Admissions: Mostly in her eighties; reluctant to be hospitalized.
  • Monocular vision (left eye, since the age of 56).
  • Appendectomy at age 45, Hip replacement at age 85.
  • Right shoulder pain since she was in her early forties. Managed with diclofenac ointments.

Recently commenced Medication:

  • Amlodipine 5 mg daily.
  • Paracetamol 500 mg as needed for pain.
  • Salbutamol inhaler as needed.
  • Furosemide 20 mg daily.
  • Allergies: None known.

Presenting Complaint:

  • Brought by two grandchildren at 06.10 AM.
  • Breathing difficulty since last night.
  • Onset: Sudden.
  • Current Status: Symptoms persist.
  • Reports backpain. Nausea.
  • Diagnosis: Nil.

Vital Signs:

  • Blood Pressure: 130/70 mmHg
  • Heart Rate: 90 bpm
  • Respiratory Rate: 24 breaths per minute
  • Temperature: 36.8°C
  • Oxygen Saturation: 92% on room air

Physical Examination:

  • General: Alert and oriented, appears slightly anxious.
  • Respiratory: Mild wheezing, decreased breath sounds bilaterally.
  • Cardiovascular: No murmurs, regular rhythm.
  • Abdomen: Soft, non-tender, no masses.
  • Extremities: No edema.

Plan:

  • Transfer to Emergency Doctor for further evaluation and management.
  • Administer oxygen therapy to maintain oxygen saturation on arrival.
  • Vital signs will be monitored during transfer (expected arrival in Caring Cross at 08.45 AM).
  • Prepare for possible nebulizer treatment.
  • Ensure patient records and medication list are transferred with the patient.

Writing Task

Using the information in the case notes, write a letter of referral to the Emergency Doctor at Caring Cross Hospital, Sydney to admit the patient and provide immediate care.

In your answer:

  • Expand the relevant case notes into complete sentences.
  • Do not use note form.
  • Use correct letter format.

The body of your letter should be approximately 200 words. Use correct letter format.

  • Question of

    Is the patient known to the recipient?

    • Yes
    • No

    Correct Wrong

  • Question of

    Who is the recipient?

    • Emergency Nurse.
    • Emergency Doctor.
    • Patient’s GP.

    Correct Wrong

  • Question of

    What is the patient’s present condition?

    • Diagnosed.
    • Treated.
    • Recuperating.
    • Undiagnosed.

    Correct Wrong

  • Question of

    What is the purpose?

    • Home Care.
    • Emergency Management.
    • Urgent Assessment.

    Correct Wrong

What do you think?

Written by Biju John

Hello, everyone! I'm Biju (IB). Welcome to Melons IB to build up your IB skills without being dependent. My field of expertise is IB English A. I am available for one-on-one tuitions. I believe that an IB student should not be helped to write, but think. Let's together start to end your IB trip!

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