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 Says Alison is also becoming withdrawn at home.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.

Model letter by Lifestyle Training Centre

School psychologist
Toohey Point Primary State School.
Barnaby Webster.

07/03/2012

Dear psychologist,
Re: Alison Cooper, DOB:14/6/2002

I am writing to refer Alison, a Year 5 student, for assessment and management to explore potential underlying grief-related or psychological issues.

Alison has been coping with the loss of her father, who tragically passed away in a motor accident 18 months ago. She frequently expresses her sadness, often crying as she misses him dearly. Currently residing with her mother, who works as a full-time bank manager, and her two siblings, aged 7 and 12, Alison’s welfare is overseen by her paternal grandmother.

Since her father’s demise, Alison’s school attendance has been irregular, and her withdrawal extends to her home environment. Notably, since Grade 3, she has faced challenges concentrating, leading to a decline in academic performance. In addition, she tends to avoid participation in sporting and class activities. Documented instances of minor physical illnesses have been addressed through medication.

Alison, the youngest in her class, faces social challenges, with limited friendships. She feels self-conscious about eczema on her hands, which has proven resistant to treatment and subjects her to teasing by classmates. Seeking solace in junk food, Alison has gained weight, 40kg, and also contends with mild asthma.

Based on the above, I kindly request a comprehensive assessment to determine if Alison is grappling with underlying grief-related or psychological concerns. Should you require additional information, please feel free to contact me.

Yours faithfully,
School nurse

(words used: 222)

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