Benchmark Referral Case Notes – John Carlos

Benchmark OET Writing Correction Service

WRITING SUB-TEST: NURSING

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TIME ALLOWED: READING TIME: 5 MINUTES
WRITING TIME: 40 MINUTES

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

Notes:
You are a pediatric cardiac intensive care nurse at Baseline Hospital.

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Today’s date: 16/1/2021
Name: John Carlos
DOB: 4/12/2010
Date of Admission: 15/1/2021 (emergency surgery)

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Diagnosis: Atrial septal defect (ASD)
Surgical Procedure: ASD closure

Patient’s History:
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• First baby of Silvester and Anna Carlos
• Born: Mama Baby Care hospital Caesarean section, term birth, birth weight: 3500 gm
• Difficulty breathing soon after birth-kept on supplemental oxygen (2L)
• Frequent C/O of LRTI (since birth)
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• Pt started school at 5 years

• Had difficulty participating in sports, SOB after physical activity for 5-10 mins
• Frequent absenteeism (LRTIs and pneumonia)

Family History:
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• Mother: aged 34, First child-social drinker

• Father: aged 38, factory clerk-smoker and social drinker
• Grandfather has CHF and DM
• Grandmother died due to MI
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15/1/2021- Emergency care

Subjective Assessment:
• C/O of severe SOB, cyanosis (lips, nail beds), lethargy, coughing (productive)
• Mild left sided chest pain
• Dizziness
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• Heart racing

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Objective Assessment:
• BP 87/54 mmHg, HR 114 b/min, O2 sat 88%, T 36.8 C
• Kept on oxygen-5L via face mask
• ECG stat-junctional tachycardia
• Echo stat-ASD (8mm)

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• Plan for urgent ASD closure
• Moved to OR

16/1/2021-Cardiac ICU Care

Subjective Assessment (1st POD):
• Stable, mild pain at surgical site dressing intact

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• R/L @ 25ml/h
• Foley catheter in place
• Complained of nausea-ondansetron administered (IV)
• No inotropic support
• IV sites intact
• Clear liquid diet

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• Drainage output: Nil (past 1 hour)
• BP 98/55 mm Hg, HR 110 b/min, T 37 C, RR 47 breaths/min
• Breathing via 2L NP
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Management Plan:
• Move to cardiac step-down
• Monitor RR and SPO2
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• D/C nasal prongs if O2 sats >100%
• Monitor I/O cautiously
• Wound site assessment-maintain asepsis
• Allow soft diet
• Involve parents in pt.’s care (hygiene care, nutrition, and ADLs)
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• Chest physiotherapy, deep breathing and coughing exercises, spirometry, suctioning

(if needed q4h)

Medications:
• Paracetamol 500mg q6h
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• Tramadol 10 mg TID
• Azithromycin 250 mg OD
• Omeprazole 15mg BD
• Nebulization with N/S and ipratropium bromide as needed
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 Writing Task

Based on the information provided in the above case notes, write a transfer letter to
the cardiology step-down nurse, Baseline Hospital, 19th Maryland Street, New York

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updating her about patient’s current management and care needs.

• DO NOT use note form in the letter.

• Expand the case notes where relevant into full sentences.
• Use formal letter format.

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The main part of the letter should be approximately 180-200 words long.

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