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

Time allowed: 40 minutes

You are the school nurse at a Toohey Point Primary State School

Today’s Date

07/03/2012

Patient Details

Alison Cooper Year 5 student

DOB: 14/6/2002

Height:138cm

Weight:40 kg Overweight for her age

Eczema outbreaks on hands and mild asthma – has ventolin inhaler

No other significant illnesses

Youngest in her class

Social History

Father died in motor accident 18 months ago.

Lives with mother, a bank manager, working full time

Middle child- brother, Simon, aged 7 and sister, Lisa, aged 12

Paternal grandmother lives near school - provides after school and holiday care
- looks after children if unwell

School Medical Record

Regular absences from school dating back to time of father’s death

Year 2: 3 days

Year 3: 4 days

Year 4: 10 days

Year 5: 8 days in first term

School Health Centre Records

2012

February 8: Complained of headache. Gave paracetemol, rested and returned to

class. Noted eczema on hands red and weepy - has ointment at home.

February 16: Complained of stomach ache. Called grandmother for pick up.
February 22: Complained of aching legs. Called grandmother for pick up.
March 4: Complained of headache. Gave paracetamol, rested 1 hour, still had
headache. Called grandmother for pickup.

March 6: Feeling nauseous - eczema on hands red and weepy. Called

grandmother for pick up.

2011

February 15: Complained of toothache. Called grandmother for pick up.

April 4: Complained of headache. Gave paracetemol - rested 1 hour.

May 14: Headache, eczema on hands red and weepy, rested 1 hour not better
called grandmother for pick up.

July 25: Feeling nauseous. Called grandmother for pick up.

August 16: Slight fever. Called grandmother for pick-up.

September 22: Feeling unwell. Eczema irritating. Called grandmother for pick
up.

October 23: Complained of stomach ache. Rested 1 hour, returned to class.

November 27: Complained of headache. Gave paracetamol, rested 30 minutes.

Social History

Alison started school well but since Grade 3 has had trouble concentrating -
rarely participates in class activities unless encouraged. Avoids sporting
activities – standard of her school work is declining. Has few friends and is
often teased by her classmates about eczema & weight. Embarrassed about
hands which don’t seem to be responding well to ointment suggested by
chemist.
Mother was contacted by class teacher regarding these issues. Says Alison is
also becoming withdrawn at home. Alison was very close to her father – often
talks to her about him and cries because she misses him. Seeks comfort in food
like chips and cakes after school.

Plan

Refer her to the school psychologist to find out whether Alison has underlying
grief related or other psychological problems.

WRITING TASK

Using the information in the case notes, write a letter to refer this girl to the
school psychologist, Barnaby Webster, to assess her. Outline the purpose of the
referral. Provide details of significant factors which will assist the psychologist
to make this assessment.

In your answer:

• Do not use note form.

• Expand the relevant case notes into full sentences.

• The body of the letter should not be more than 200 words.

• Use correct letter format.