Task 4 Case Notes: Margaret Leon
Read the cases notes below and complete the writing task that follows
Time allowed: 40 minutes
Margaret Leon 01 .08. 52
Regular patient in your General Practice .
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
BP 160/90 PR 70 regular
Wt 69 kg
On no medication
No known allergies
Overweight. Advised on exercise & weight reduction.
Review in 3 months
Feeling better in part due to weight loss
PR 70 regular
Wt 61 kg
Making good progress with weight. Blood pressure within normal range
Saw blood in the toilet bowl on two occasions after bowel motions. Depressed and very anxious. Believes she has bowel cancer. Trouble sleeping.
BP 180/95 P 88 regular
Ht 152cm Wt 50 kg
Cardiovascular and respiratory examination normal.
Rectal examination shows no obvious abnormalities.
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
Write a letter addressed to Dr. William Carlson, 1st Floor, Ballow Chambers, 56 Wickham Terrace, Brisbane, 4001 requesting his opinion.
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 4 Model Letter: Margaret Leon
Dr. William Carlson
56 Wickham Tce
Dear Doctor Carlson,
Re: Margaret Leon
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.
Dr X (GP)
Word Length: 194 words