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Admission Letter

This referral letter is regarding 8-year old Amina Ahmed, who is being referred for admission to the Emergency Pediatric Unit at Brisbane General Hospital for further investigation and treatment of suspected meningococcal meningitis. Amina initially presented with fever, runny nose, cough and appetite loss and was treated as a viral infection, but her condition deteriorated with worsening headache, lethargy and vomiting. On examination she had neck stiffness, rash, fever of 40.2°C and pulse of 110. Blood tests showed leukocytosis with left shift. The doctor suspects meningococcal meningitis and provided initial penicillin treatment. Urgent admission is requested for further assessment and management.

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Yasir KN
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475 views4 pages

Admission Letter

This referral letter is regarding 8-year old Amina Ahmed, who is being referred for admission to the Emergency Pediatric Unit at Brisbane General Hospital for further investigation and treatment of suspected meningococcal meningitis. Amina initially presented with fever, runny nose, cough and appetite loss and was treated as a viral infection, but her condition deteriorated with worsening headache, lethargy and vomiting. On examination she had neck stiffness, rash, fever of 40.2°C and pulse of 110. Blood tests showed leukocytosis with left shift. The doctor suspects meningococcal meningitis and provided initial penicillin treatment. Urgent admission is requested for further assessment and management.

Uploaded by

Yasir KN
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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TIME ALLOWED: READING TIME: 5 MINUTES Task 14 WRITING TIME: 40 MINUTES

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

notes:

Today’s Date 14.10.12


Patient History Amina Ahmed aged 8 years – new patient at your clinic Parents – Mother Ayama, house-
wife. Father Talan, cab driver Brothers Dalma aged 4 and Roble aged 2 Family refugees from Somali
2005. Have Australian Citizenship Amina and father good understanding of English, mother has basic
understanding of slowly spoken English. Amina had appendicectomy 2 years ago. No known allergies

09/10/12

Subjective

Fever, runny nose, mild cough, loss of appetite Unable to attend school

Objective

Pulse 85/min Temperature 39.4 No rash No neck stiffness CVS, RS & abdo – normal

Assessment Viral infection

Management Keep home from school Rest and paracetamol three times daily Review in 3 days if no
improvement

12/10/12

Subjective

Amina not well Cough +, continuous headache, lethargic, loss of appetite Difficult to control
temperature with Paracetamol Mother worried

Objective

Fever 39.8 C No rash or neck stiffness

Management Prescribe Brufen 200mg as required FBC & UFR were ordered Review in two days with
results of reports

14/10/12

Subjective Both parents very concerned Reported Amina lethargic and listless Vomited twice last night
and headaches worse

Objective
FBC- WBC(18000) and left shift Urinary Function Report Normal Temperature 40.2C Pulse 110/min
Macula-papular rash over legs Neck Stiffness+

Assessment Meningococcal meningitis. Penicillin IV given (stat dose)

Plan Arrange urgent admission to the Emergency Paediatric Unit, Brisbane General Hospital, for further
investigation and treatment.

Writing Task: You are GP, Dr. Lucy Irving, Kelvin Grove Medical Centre, 53 Goma Rd, Kelvin Grove,
Brisbane. Write a referral letter to the Duty Registrar, Emergency Paediatric Unit, Brisbane General
Hospital, 140 Grange Road, Kelvin Grove, QLD, 4222.

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.
Duty Registrar

Emergency Pediatric Unit

Brisbane General Hospital

140 Grange Road

Kelvin Grove

QLD 4222

14.10.12

Dear Doctor,

Re: Amina Ahmed, Aged 8

I am writing to request for an urgent admission for further investigation and treatment for Amina,
whose features are suggestive of meningococcal meningitis.

Amina, who was under my treatment as a case of viral infection for 5 days, visited today with anxious
parents as her condition was progressively deteriorating. She had severe headache, lethargy, listlessness
and vomiting. Examination showed neck stiffness, maculo-pappular rash over the legs, temperature
-40.2*c, pulse – 110/min. Blood report showed leukocytosis with left shift. With all this features I
suspect meningococcal meningitis and started penicillin IV, stat dose of which has been given.

Initially, on 09/10/12 she presented with fever, runny nose, mild cough and loss of appetite and
managed with paracetamol and rest. As her condition did not improve, 2 days ago I instituted Brufen
200mg and ordered for blood and urine tests. All her observations were normal during both visits except
the temperature which were 39.4 *c and 39.8*c accordingly.

Please note that, Amina has no known allergy. She lives with her parents and two younger siblings, aged
4 and 2.Moreover she is school going. Although her family emigrated from Somalia 7 years back they
understand English.

It would be appreciated if you arrange an urgent admission for her assessment and management. If you
have any queries don’t hesitate to contact me.

Yours faithfully,

Dr Lucy Irving

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