The task
Assume that today's date is 17 October 2026. Mr Wickramasinghe is going home from the ward this afternoon.
You are a registered nurse on the medical ward. Using the information in the case notes, write a letter to Ms Niamh Feeney, Clinical Nurse Consultant of the Hospital in the Home Service, referring Mr Wickramasinghe for daily intravenous antibiotics, PICC line care and monitoring at home. Address the letter to Ms Niamh Feeney, Clinical Nurse Consultant, Hospital in the Home Service, Level 1, 85 Harbour Road. In your answer: expand the relevant notes into complete sentences; do not use note form; use letter format. The body of the letter should be approximately 180–200 words.
Length: the body of the letter should be about 180–200 words. You have 45 minutes in the test: 5 minutes to read, 40 to write. Letter type: Referral letter.
Case notes
Patient details
- Name: Mr Tunde Wickramasinghe
- DOB: 03/05/1979 (47 yrs)
- Address: Unit 4, 12 Fern Street
- Admitted: 14/10/26; transfer to HITH: 17/10/26
- Allergy: adhesive plaster tape → skin blistering
Social background
- Lives with wife; she works from home, can provide transport & help with leg elevation
- Bus driver; on sick leave, keen to return to work ASAP
- Enjoys fishing at weekends
- Smoker 10 cigs/day; brief intervention given, declined NRT
- Wife told staff pt is 'lazy about looking after his feet'
- Two-storey house, bedroom upstairs; managing stairs independently
Medical history
- Type 2 diabetes (6 yrs): metformin 1 g BD; HbA1c 7.4%
- Obesity (BMI 34)
- Appendicectomy 1998
- Tinea pedis R foot (between toes) — likely entry point for infection
Admission
- R lower-leg cellulitis: spread despite 3 days oral flucloxacillin from GP; erythema & swelling ankle → mid-shin; T 38.6°C on arrival
- Blood cultures: no growth at 48 hrs; US leg: no collection, no DVT
- IV cefazolin 2 g 8-hourly 14–17/10 → from 18/10: probenecid 1 g PO 30 min before each dose of cefazolin 2 g IV once daily (HITH regimen)
Progress
- Afebrile since 15/10; HR & BP WNL
- Erythema receding: border marked with skin pen 16/10; now ankle → lower third of shin
- CRP 162 → 58 mg/L (14/10 → 17/10)
- Pain ↓ 7/10 → 3/10. D/C medication review 17/10 (MO & pharmacist): probenecid ↓ paracetamol clearance → ward paracetamol PRN order ceased; pt advised not to take OTC paracetamol; HITH MO to review if analgesia needed
- Mobilising independently; elevating leg when sitting
- BGLs 7–12 mmol/L on ward
- Complained re: hospital meals 'always cold'
PICC line
- Single-lumen PICC L arm (basilic vein) inserted 16/10/26; tip position confirmed on CXR
- External length 2 cm; site clean, no redness/swelling/ooze
- Secured with clear semi-permeable dressing (tolerated, no tape) — next dressing change due 23/10
- Flush with sodium chloride 0.9% before & after each dose per protocol
Plan
- HITH daily visits from 18/10: confirm probenecid 1 g taken 30 min before cefazolin, give IV cefazolin, obs, check leg against marked border, PICC care
- Escalate: fever, erythema spreading beyond border, ↑ pain, line problems (arm pain/swelling, site redness, occlusion) → HITH medical officer; signs of sepsis → ambulance/ED
- Oral switch assessed by medical team 17/10: not yet suitable (failed oral flucloxacillin pre-admission; erythema still extensive) → continue IV via HITH. HITH MO to reassess IV need within 48 hrs (by 19/10) & at each review; switch to oral & remove PICC as soon as criteria met
- Continue clotrimazole 1% cream to R toe webs BD
- GP to review diabetes & smoking after HITH discharge
Who is reading, and what do they need?
Ms Feeney is a clinical nurse consultant who will accept the referral and direct daily visits. She is clinically expert, so she needs the diagnosis, the exact regimen, progress markers, PICC details, the paracetamol restriction, escalation and review dates, without basic explanation or social detail.
What to include
Selection is the skill the Content and Conciseness criteria reward. These notes earn their place:
| Case note | Why it belongs |
|---|---|
| R lower-leg cellulitis spread despite 3 days oral flucloxacillin; tinea pedis likely entry | Gives the diagnosis, the failed oral treatment and the probable source, which is treated with clotrimazole. |
| From 18/10 probenecid 1 g PO 30 min before cefazolin 2 g IV once daily | The regimen changed from 8-hourly cefazolin, so visiting nurses must confirm probenecid timing and give the once-daily dose. |
| Afebrile since 15/10; CRP 162 to 58; pain 3/10; border marked | Progress markers and the marked border give the baseline for monitoring. |
| Probenecid reduces paracetamol clearance; PRN ceased; no OTC paracetamol | A safety point: the patient has been advised, and the HITH medical officer reviews analgesia if needed. |
| Single-lumen PICC L basilic 16/10; 2 cm external; site clean; tip confirmed | The nurse needs line details for care, including saline flushes before and after each dose. |
| Allergy to adhesive tape; clear semi-permeable dressing, no tape; change due 23/10 | Prevents a tape-related skin injury and flags a dated task within the visiting period. |
| Oral switch not suitable yet; HITH MO reassess by 19/10 and each review | States why IV continues and when it will be reviewed, with PICC removal once switch criteria are met. |
| Escalation: fever, spread past border, more pain, line problems; sepsis signs to ambulance/ED | Gives the complete escalation set and destinations. Also mention clotrimazole BD and GP review of diabetes and smoking after discharge. |
What to leave out or compress
| Case note | Why it goes |
|---|---|
| Wife says he is 'lazy about looking after his feet' | Trap: it seems linked to the tinea, but it is a judgemental third-party comment, not a clinical finding. |
| Bus driver on sick leave; enjoys fishing | Occupation and hobby do not affect the HITH plan, and the notes give no work advice. |
| Smoker 10/day; brief intervention given, declined NRT | Handled by the GP after discharge. Mention only as part of that GP review. |
| Blood cultures no growth at 48 hrs; ultrasound no collection or DVT | Compress or omit. HITH needs the treatment plan more than the negative investigation details. |
| Hospital meals 'always cold' | A ward complaint with no bearing on home treatment. |
| Appendicectomy 1998; BMI 34 | Remote or background history with no effect on the visits. |
A paragraph plan for this case
Open with the referral request, then diagnosis, failed oral therapy and progress. Next cover the regimen, the paracetamol restriction and PICC details with tape allergy, and finish with escalation, review timing, topical treatment and GP follow-up.
Where candidates slip on this task
- State the regimen change clearly: from 18/10 cefazolin 2 g IV is once daily, with probenecid 1 g by mouth 30 minutes before each dose. Do not repeat the earlier 8-hourly schedule as current.
- Word the paracetamol point carefully: the ward order is stopped because of probenecid, he is advised against over-the-counter paracetamol, and the HITH medical officer reviews analgesia. Do not say he needs no pain relief.
- Include the 48-hour reassessment by 19/10, the 23/10 dressing change and the tape allergy. Do not state that the infection is resolved, since erythema is receding but still present.
No model letter is published here. Write for the named reader from the case notes in the timed editor, then get it marked.
Write it in the timed editor and get marked on the 6 criteria
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Your profession's guide: OET Nursing. Layout and structure: OET letter format.
Questions about this task
Do I need his diabetes details?
Briefly. Type 2 diabetes on metformin and ward glucose readings of 7–12 mmol/L are relevant to monitoring, and the GP will review diabetes afterwards. HbA1c and obesity detail can be left out.
Why explain why oral therapy is not yet suitable?
The medical team assessed it on 17/10 and decided against it because oral flucloxacillin failed before admission and erythema is still extensive. This justifies HITH acceptance and sets up the early reassessment.
Sources
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