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

Time allowed: 40 minutes

You are the school nurse at a Toohey Point Primary State School

Today’s Date

07/03/2012

Patient Details

Alison Cooper
Year 5 student
DOB: 14/6/2002
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

2012

February 8: Complained of headache. Gave paracetemol, rested and returned to class. Noted
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. Gave parcetemol, 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.

2011
February 15: Complained of toothache. Called grandmother for pick up.
April 4: Complained of headache. Gave paracetemol - 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 irritating. Called grandmother for pick up.
October 23: Complained of stomach ache. Rested 1 hour, returned to class.
November 27: Complained of headache. Gave paracetemol, 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 about eczema
& weight. 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withdrawn at home.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.
In your answer:

• Do not use note form.

• Expand the relevant case notes into full sentences.
• The body of the letter should not be more than 200 words.
• Use correct letter format.

07/03/2012

Barnaby Webster
The School Psychologist
Toohey Point State School
Dear Mr. Webster,

Re: Alison Cooper

DOB: 14/06/02

I am writing to refer Alison, a year 5 student at our school due to possible psychological
problems and low self esteem.

Alison lives with her mother, who is working full-time as a bank manager. She has an older
sister and a younger brother. Her grandmother looks after the children when required. In
terms of her medical history, she is suffers from asthma and eczema with no other significant
illnesses. She is overweight for her age.

Alison’s father died 18 months ago due to a motor accident. Since that time, there have been
a number of changes in Alison’s behaviour which I am concerned about. Her school health
records indicate that she has been regularly absent from class due to minor illnesses which I
suspect may be due to psychological rather than physical problems. In addition, her academic
performance is declining and she is reluctant to join in any class or sporting activities unless
persuaded. She has few friends and has been teased by her peers about her eczema and
weight.

Please note, Alison’s teacher contacted her mother regarding her situation and she reported
that Alison is overeating, embarrassed about her eczema and missing her father, who she was
very close to.

Based on this, I would appreciate it if you could investigate her case. Should you require any
further information please do not hesitate to contact me.

Yours sincerely,

Charge Nurse
Toohey Point State School