Case Notes: Margaret Leon

Task 4 Case Notes: Margaret Leon

नीचे दिए गए केस नोट्स को पढ़ें और उसके बाद दिए गए लेखन कार्य को पूरा करें

समय दिया गया: 40 मिनट

आज की तारीख

03.07.12

रोगी का इतिहास
Margaret Leon 01 .08. 52

Gender: Female

Regular patient in your General Practice .

14.01.12
व्यक्तिपरक
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

उद्देश्य
BP 160/90 PR 70 regular
Ht 152cm
Wt 69 kg
On no medication
No known allergies

आकलन
Overweight. Advised on exercise & weight reduction.
Borderline hypertension
Review in 3 months

25.04.12
व्यक्तिपरक
Feeling better in part due to weight loss

उद्देश्य
BP 140/85
PR 70 regular
Ht 152cm
Wt 61 kg

आकलन
Making good progress with weight. Blood pressure within normal range

03.07.12

व्यक्तिपरक
Saw blood in the toilet bowl on two occasions after bowel motions. Depressed and very anxious. Believes she has bowel cancer. Trouble sleeping.

उद्देश्य
BP 180/95 P 88 regular
Ht 152cm Wt 50 kg
Cardiovascular and respiratory examination normal.
Rectal examination shows no obvious abnormalities.

आकलन
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

लेखन कार्य

Write a letter addressed to Dr. William Carlson, 1st Floor, Ballow Chambers, 56 Wickham Terrace, Brisbane, 4001 requesting his opinion.

आपके उत्तर में:

प्रासंगिक केस नोट्स को पूर्ण वाक्यों में विस्तारित करें
नोट फॉर्म का उपयोग न करें
पत्र का मुख्य भाग लगभग 180~200 शब्दों का होना चाहिए
सही पत्र प्रारूप का उपयोग करें
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.

सादर,

Dr X (GP)

Word Length: 194 words