Task 2 Case Notes: James Warden
Read the cases notes below and complete the writing task which follows
Time allowed: 40 minutes
Regular patient in your General Practice
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.
BP 155/85 P 80 regular
Cardiovascular and respiratory examination normal
Slight swelling in right groin consistent with inguinal hernia.
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
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.
BP 140/80 P70 regular
Marked increase in swelling in right groin and small swelling in left groin.
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.
Write a letter addressed to Dr. Glynn Howard, 249 Wickham Tce, Brisbane, 4001 explaining the patient’s current condition.
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 2 Model Letter: James Warden
Dr. Glynn Howard
249 Wickham Tce
Re: Mr. James Warden
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.
Dr X (GP)