Task 5 Case Notes: Darren Walker
Read the cases notes below and complete the writing task which follows
Time allowed: 40 minutes
Today’s Date
15.08.12
Patient History
Darren Walker
DOB 05.07.72
Regular patient in your General Practice
09.07.12
Subjective
Regular check up, Family man, wife, two sons aged 5 and 3
Parents alive – father age 71 diagnosed with prostate cancer 2002.
Mother age 68 hypertension diagnosed 2002.
Smokes 20 cigarettes per day –trying to give up
Works long hours – no regular exercise
Light drinker 2 –3 beers a week
Objective
BP 165/90 P 80 regular
Cardiovascular and respiratory examination normal
Height 173 cm Weight 85kg
Urinalysis normal
Plan
Advise re weight loss, smoking cessation
Review BP in 1 month
Request PSA test before next visit
14.08.12
Subjective
Reduced smoking to 10 per day
Attends gym twice a week, Weight 77 kg
Complains of discomfort urinating
Objective
BP 145/80 P76
DRE hardening and enlargement of prostate
PSA reading 10
Plan
Review BP, smoking reduction in 2 months
Refer to urologist – possible biopsy prostate
Writing Task
Write a referral letter addressed to Dr. David Booker (Urologist), 259 Wickham Tce, Brisbane 4001. Ask to be informed of the outcome.
In your answer:
Expand the relevant case notes into complete sentences
Do not use note form
The body of the letter should be approximately 180~200 words
Use correct letter format
Task 5 Model Letter: Darren Walker
15/08/2012
Dr. David Brooker (Urologist)
The Urology Department
259 Wickham Tce
Brisbane, 4001
Dear Doctor,
Re: Mr. Darren Walker
I am writing to refer this patient, a 40 year old married man with two sons aged 3 and 5, who requires screening for prostate cancer.
Initial examination on 09/07/12 revealed a strong family history of related illness as his elderly father was diagnosed with prostate cancer and mother was diagnosed as hypertensive. Mr Walker is a smoker and light drinker. He works long hours and does not do any regular exercise. His blood pressure was initially 165/90 mmhg and pulse was 80 and regular. He is 173cm tall and his weight, at that time, was 85 kg. He was advised to reduce weight and stop smoking and a prostate specific antigen test was requested. There were no other remarkable findings.
When he came for the next visit on 14/08/2012, Mr Walker had reduced smoking from 20 to 10 cigarettes per day and was attending gym twice a week. He had lost 8kg of weight. His blood pressure was improved at 165/90mmhg. However digital rectal examination revealed an enlarged prostate and the PSA reading was 10.
In view of the above signs and symptoms, I believe he needs further investigations including a prostate biopsy and surgical management. I would appreciate your urgent attention to his condition.
Yours sincerely,
Dr.X
Word Length: 206 words
