TASK 60 You are the school nurse at Toohey Point Primary State School Today’s Date
07/03/2010
Patient Details: Alison Cooper Year 5 student DOB: 14/6/2000. 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
2010 February 8: Complained of headache. Have paracetamol, rested and returned to class. 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. Have 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.
2009 February 15: Complained of toothache. Called grandmother for pick up April 4: Complained of headache. Have paracetamol-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 irritation. Called grandmother for pick up. October 23: Complained of stomach ache. Rested 1 hour, returned to class November 27: Complained of headache. Have 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. 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 Says Alison is also becoming withdrawn at home.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.
View sample answer by Lifestyle Training Centre
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