Task 4 Case Notes: Margaret Leon
اقرأ ملاحظات الحالات أدناه وأكمل مهمة الكتابة التي تليها
الوقت المسموح به: 40 دقيقة
تاريخ اليوم
03.07.12
تاريخ المريض
Margaret Leon 01 .08. 52
Gender: Female
Regular patient in your General Practice .
14.01.12
شخصي
Wants general check up, single, lives with and takes care of elderly mother.
Father died bowel cancer aged 50.
Had colonoscopy 3 years ago. Clear
Does not smoke or drink
موضوعي
BP 160/90 PR 70 regular
Ht 152cm
Wt 69 kg
On no medication
No known allergies
تقدير
Overweight. Advised on exercise & weight reduction.
Borderline hypertension
Review in 3 months
25.04.12
شخصي
Feeling better in part due to weight loss
موضوعي
BP 140/85
PR 70 regular
Ht 152cm
Wt 61 kg
تقدير
Making good progress with weight. Blood pressure within normal range
03.07.12
شخصي
Saw blood in the toilet bowl on two occasions after bowel motions. Depressed and very anxious. Believes she has bowel cancer. Trouble sleeping.
موضوعي
BP 180/95 P 88 regular
Ht 152cm Wt 50 kg
Cardiovascular and respiratory examination normal.
Rectal examination shows no obvious abnormalities.
تقدير
Need to investigate for bowel cancer
Refer to gastroenterologist for assessment /colonoscopy.
Prescribe 15 gram Alepam 1 tablet before bed.
Advise patient this is temporary measure to ease current anxiety/sleeplessness.
Review after BP appointment with gastroenterologist
مهمة الكتابة
Write a letter addressed to Dr. William Carlson, 1st Floor, Ballow Chambers, 56 Wickham Terrace, Brisbane, 4001 requesting his opinion.
في إجابتك:
قم بتوسيع ملاحظات الحالة ذات الصلة إلى جمل كاملة
لا تستخدم نموذج الملاحظة
يجب أن يكون نص الرسالة حوالي 180 إلى 200 كلمة
استخدم تنسيق الحرف الصحيح
Task 4 Model Letter: Margaret Leon
03/07/2012
Dr. William Carlson
First Floor
Ballow Chamber
56 Wickham Tce
Brisbane 4001
Dear Doctor Carlson,
Re: Margaret Leon
DOB 01/08/1952
Thank you for seeing my patient, Margaret Leon, who has been very concerned about blood in her stools. She has seen blood in the toilet bowl on two occasions after bowel motion. She is very anxious. as well as being depressed because her father died of bowel cancer and she feels she may have the same condition.
Margaret has otherwise been quite healthy. She does not drink or smoke and is not taking any medication. She was slightly overweight six months ago with borderline high blood pressure. At that time, I advised her to lose weight which she did successfully. Three months later, her weight had dropped from 69kg to 61kg and blood pressure was back within the normal range.
On presentation today, she was distressed because she believes she has bowel cancer. She has had trouble sleeping and her weight has reduced a further 11 kg. The rectal examination did not show any abnormalities. Her blood pressure was slightly elevated at 180/95 but her cardiovascular and respiratory examination was unremarkable. Alepam, one before bed, was prescribed to control the anxiety and sleeplessness.
I would appreciate it if you could perform a gastroenterology assessment.
مع خالص تحياتي،
Dr X (GP)
Word Length: 194 words
AR 
EN_GB 
HI