Task 3 Case Notes: Dulcie Wood
Read the cases notes below and complete the writing task which follows:
Time allowed: 40 minutes
New patient in your general practice. Moved recently to be near family.
Widowed January 06, three children, wants regular check up, has noticed uncomfortable feeling in her chest several times in the last few weeks like a heart flutter.
Mother died at 52 of acute myocardial infarction, non smoker, rarely drinks alcohol
Current medication: zocor 20mg daily, calcium caltrate 1 daily
No known allegeries
BP 145/75 P 80 regular
Ht 160cm Wt 61kg
Cardiovascular and respiratory examination normal ECG normal
Prescribe Noten 50 gm ½ tablet daily in am. Advise to keep record of frequency of fibrillation sensation.
Review in 2 weeks if no increase in frequency.
Reports sensations less but woke up twice at night during last 2 weeks
BP 135/75 P70 regular
Increase Noten to 50 gm daily ½ tablet am and ½ tablet pm
Advise review in one month.
Initial improvement but in last 3 days heart seems to be fluttery several times a day and also at night. Very nervous and upset. Wants a referral to a cardiologist Dr. Vincent Raymond who treated her sister for same condition
BP 180/90 P70
Contact Dr. Raymond’s receptionist and you are able to arrange an appointment for Mrs. Wood at 8am on 14/08/12
Write a letter addressed to Dr. Vincent Raymond, 422 Wickham Tce, Brisbane 4001 describing the situation.
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 3 Model Letter : Dulcie Wood
Dr Vincent Raymond
422 Wickham Tce
Dear Dr. Raymond,
Re: Dulcie Wood
As arranged with your receptionist, I am referring this patient, a 66 year old widow, who has been demonstrating symptoms suggestive of heart arrhythmia.
Mrs. Woods has seen me on several occasions over the past five months, during which time she has had frequent episodes of heart flutter and her blood pressure has been fluctuating.
The patient initially responded to Noten 50mg ½ tablet daily in the morning, but she still had episodes of disturbed sleep during the night. Therefore the dose of Noten was increased to 50mg ½ tablet in the morning and ½ tablet at night, but unfortunately her heart flutter has increased recently, especially over the last three days. Other current medications are Zocor 20mg and Calcium Caltrate 1 daily.
Today’s examination revealed a nervous and upset woman with a pulse rate of 70 and blood pressure of 180/90.
Please note that her mother died of acute myocardial infarction and her sister, who is a patient of yours, has a similar condition.
In view of the above, I would appreciate it if you provide an assessment of Mrs. Wood and advise regarding treatment and management of her condition.
Word Length: 191 words