Task 1 Case Notes: Cathy Jones
Read the cases notes below and complete the writing task that follows
Time Allowed
Reading Time: 5 minutes
Writing Time: 40 minutes
Today’s Date
16.02.13
Patient History
Miss Cathy Jones – 25 year old single woman
Occupation – receptionist
Family history of deep vein thrombosis
On progesterone-only pill (POP) for contraception
No previous pregnancies
15.02.13
Subjective
Presents to GP surgery at 7 pm, after work
Complains of lower abdominal pain since the evening before, worse in right iliac fossa
Unsure of last menstrual period, has had irregular bleeding since starting
POP 2 months ago, New partner for past 2 months
No bladder or bowel symptoms
Objective
Mild right iliac fossa tenderness, no rebound / guarding
Apyrexial, pulse 88, BP 110/70
Vaginal examination – quite tender in right fornix. No masses
Assessment
Non-specific abdo pain
Plan: Asks her to return in morning for blood test and reassessment
16.02.13
Subjective
Pain has worsened overnight. Now severe constant pain.
Some slight vaginal bleeding overnight also.
Felt faint while waiting in reception.
On questioning, has left shoulder-tip pain also.
Objective
Very tender in the right iliac fossa, with guarding and rebound tenderness
Apyrexial, Pulse 96, BP 110/70
On vaginal examination, has cervical excitation and markedly tender in the right fornix.
Pregnancy test result positive
Urine dipstick clear
Assessment
Suspected ectopic pregnancy
Plan: You ring the on duty Gynaecology Registrar and ask for urgent assessment, and are instructed to send her to the A&E Department with a referral letter.
Writing Task
You are the GP, Dr Sally Brown. Write Referral letter to the Gynaecology Registrar at the Spirit Hospital, South Brisbane. Ask to be kept 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 1 Model Letter: Cathy Jones
16/02/13
Gynaecology Registrar
A&E Department
Spirit Hospital
South Brisbane
Dear Doctor,
Re: Cathy Jones
Thank you for seeing this 25-year-old woman, who I suspect has an ectopic pregnancy.
This is her first pregnancy. Ms. Jones presented to the surgery yesterday evening with vague lower abdominal pain. She started the progesterone-only pill for contraception two months ago, when she started a new relationship, and has had some irregular bleeding since then. Therefore, she is unsure of her exact last menstrual period. Yesterday, she was mildly tender only and her observations were normal.
However, on review this morning her pain had worsened overnight, she is very tender in the right iliac fossa, with rebound and guarding, and on vaginal examination there is cervical excitation, and marked tenderness in the right fornix. Her pregnancy test is positive.
I am concerned that she may have an ectopic pregnancy, and would appreciate your urgent assessment.
Please keep me informed of the outcome.
Yours sincerely,
Dr. Sally Brown (GP)
