Task 2 Case Notes: James Warden
Read the cases notes below and complete the writing task which follows
الوقت المسموح به: 40 دقيقة
تاريخ اليوم
25.08.12
تاريخ المريض
James Warden
DOB 05.07.32
Regular patient in your General Practice
09.07.12
شخصي
Wants regular check up, has noticed small swelling in right groin.
Hypertension diagnosed 5 years ago, non smoker, regularly drinks 2 – 4 glasses of wine nightly and 1 – 2 glasses of scotch at weekend.
Widower living on his own ,likes cooking and says he eats well.
Current medication noten 50 mg daily, ½ aspirin daily, normison 10mg nightly when required, fifty plus multivitamin 1 daily, allergic reaction to penicillin.
موضوعي
BP 155/85 P 80 regular
Cardiovascular and respiratory examination normal
Urinalysis normal
Slight swelling in right groin consistent with inguinal hernia.
يخطط
Advised reduction of alcohol to 2 glasses maximum daily and at least one alcohol free day a week.
Discussed options re hernia. Patient wants to avoid surgery.
Advised to avoid any heavy lifting and review BP and hernia in 3 months
25.08.12
شخصي
Had problem lifting heavy wheelbarrow while gardening. Has a regular dull ache in
right groin, noticed swelling has increased.
Has reduced alcohol intake as suggested.
موضوعي
BP 140/80 P70 regular
Marked increase in swelling in right groin and small swelling in left groin.
تقدير
Bilateral inguinal hernia
Advise patient you want to refer him to a surgeon. He agrees but says he wants a
local anaesthetic as a friend advised him he will have less after effects than with general anaesthetic.
مهمة الكتابة
Write a letter addressed to Dr. Glynn Howard, 249 Wickham Tce, Brisbane, 4001 explaining the patient’s current condition.
في إجابتك:
قم بتوسيع ملاحظات الحالة ذات الصلة إلى جمل كاملة
لا تستخدم نموذج الملاحظة
The body of the letter should be approximately 180~ 200 words
استخدم تنسيق الحرف الصحيح
Task 2 Model Letter: James Warden
25/08/2012
Dr. Glynn Howard
Surgical Department
249 Wickham Tce
Brisbane 4001
عزيزي الطبيب،
Re: Mr. James Warden
DOB 05/07/32
I am referring this patient, a widower, who is presenting with symptoms consistent with a bilateral inguinal hernia. He has been suffering from hypertension for 5 years for which he takes Noten, Aspirin and multivitamins. He is allergic to penicillin.
Initially, Mr. Warden presented to me on 09/07/12 for a regular check up. On examination, he had a mild swelling of the right groin, his blood pressure was 155/85 and pulse was 80 beats per minute. Otherwise his condition was normal. He was diagnosed as having an inguinal hernia. I discussed the possibility of surgery; however, he indicated he did not want an operation. Therefore, I advised that he avoid heavy lifting and reduce alcohol consumption. A review consultation was scheduled for 3 months later.
Today he returned complaining that his right groin had increased in size with a regular dull ache possibly due to lifting a heavy wheel barrow. The examination revealed a considerable increase in the swelling in the right groin as well as a mild swelling of the left groin.
Based on my provisional diagnosis of a bilateral inguinal hernia, I would like to refer him for surgery as early as possible. Please note that he wishes to have the surgery under local anaesthesia.
مع خالص تحياتي،
Dr X (GP)
AR 
EN_GB 
HI