Writing time: 40 minutes

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

Mihiraa, an 8-year-old, is a patient in the accident and emergency department of the hospital in which you are the Charge Nurse.

Notes

Date: 20 July 2024

Patient: Mihiraa, 8 years old (F)

Presenting Complaint: Fall from bicycle 1 hour ago.

History of Present Illness:

•  Patient fell from her bicycle and hit her head on a gate post. There is no reported loss of consciousness but the child is pale and lethargic.
• Mother reports she was not wearing a helmet at the time of the accident.
• Witnessed by the mother who arrived at the scene immediately.
• Patient complained of initial pain in her right elbow and some dizziness.
• No vomiting or nausea.

Past Medical History: No significant past medical history.

Allergies: No known allergies.

Medications: None currently.

Social History: Lives with mother and father. Active child who enjoys cycling.

Family History: Non-contributory.

Observation:

• General: Appears alert and oriented to time, place, and person. Cooperative throughout the examination.
• Vital Signs:
  • Temperature: 37.0°C (axillary)
  • Pulse: 88 bpm
  • Respirations: 16 per minute
  • Blood pressure: 110/70 mmHg (right arm)
• Head: Large bump on forehead (size and colour to be documented)
• Skin: Pale skin
• Eyes: Pupils equal, round, and reactive to light (PERRLA).
• Ears, Nose, Throat (ENT): Normocephalic. No discharge from ears or nose. Oral mucosa moist.
• Neck: Supple, no lymphadenopathy.
• Cardiovascular: Regular rhythm, no murmurs.
• Respiratory: Clear to auscultation bilaterally.
• Abdomen: Soft, non-tender, no organomegaly.
• Musculoskeletal: Right elbow point tenderness and mild swelling noted. Full range of motion in both elbows, although reports pain with flexion and extension of the right elbow. No other obvious injuries identified.

Assessment:

• Head injury (mechanism: fall from bicycle, direct blow to head)
• Possible concussion (due to lethargy)
• Likely right elbow contusion.

Plan:

• X-ray of right elbow to rule out fracture.
• Observe for signs of worsening concussion (vomiting, worsening headache, confusion) for the next 24 hours.
• Apply ice pack to the right elbow for 15-20 minutes at a time, several times a day.
• Simple analgesia (paracetamol) for pain relief if needed.
• Advise on wearing a helmet at all times while cycling.
• Follow-up appointment in 2 days to review X-ray results and assess recovery.
• Advise parent/guardian on concussion signs and symptoms and to seek immediate medical attention if any concerns arise.

Education:

• Mother educated on signs and symptoms of concussion and advised to seek immediate medical attention if any concerns arise.
• Importance of helmet use while cycling emphasized.

Disposition:

• Discharged home with mother following assessment and instruction.

Writing Task

Using the information given in the case note, Write a letter to GP Dr. Mendiz Green, regarding Mihiraa’s condition. Address your letter to Dr. Mendiz Green, GP. Maraville.

In your answer
• Expand the relevant case notes into complete sentences
• Do not use note form
• Use letter format
The body of the letter should be approximately 180-200 words. 

SAMPLE ANSWER

Dr. Mendiz Green
General Practitioner
Maraville

20 July 2024

Dear Dr Green

Re: Mihiraa, aged 8

I am writing to update you regarding Mihiraa who had a fall from a bicycle. She has been discharged home today.

Mihiraa sustained a head injury after colliding with a gate post. Her mother, who witnessed the accident, reported that Mihiraa was not wearing a helmet. On examination, she presented with a large forehead contusion, pallor, and lethargy. She also had tenderness and swelling of her elbow. Her vital signs and neurological examination were unremarkable.

Mihiraa was treated with paracetamol as needed and an ice pack application. Her mother was educated on the signs and symptoms of concussion and advised to seek immediate medical attention if any concerns arise. The importance of helmet use while cycling was emphasized.

Mihiraa’s X-ray of the right elbow was ordered to rule out a fracture. She has a follow-up appointment in two days to review the X-ray results and assess her overall recovery.

Please feel free to contact me for further concerns.

Yours sincerely

Registered Nurse