Benchmark Case Notes - 100522

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Case Notes Study 1
Benchmark OET Writing Correction Service
WRITING SUB-TES: MEDICINE

TIME ALLOWED: READING TIME: 5 MINUTES
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WRITING TIME: 40 MINUTES
Read the case notes and complete the writing task which follows.
Notes:
You are a junior physician working at Cow Bay Primary Health Clinic, 69 Tea Tree Rd, Diwan QLD 4873,
Australia, and Mrs. Julia Smith has presented in active labor and baby was delivered successfully.
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PATIENT DETAILS:
Name: Julia Smith

Age: 21
Husband: Mason Smith
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Past history:
• No records available, from Cyprus, visiting in-laws in Australia
• Used to get monthly visits from local midwife
• No hospital visits
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• No vaccinations
• Allergies unknown
Family History:
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• Mother diabetic
• Father hypertensive, had stroke 2 years back
• 2 elder sisters, eldest diabetic
• 4 brothers, 2 hypertensive and diabetic
• 1 had inguinal hernia
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05-12-2021
SUBJECTIVE:
• G1 P0
• 30 weeks of gestation
• Vaginal bleeding small amount
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• Burst water bag 6 hrs ago

• Severe abdominal and back pain, episodic
OBJECTIVE:
08:04 A.M
• Bloody show occurred
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• Ruptured amniotic membranes

• Strong uterine contractions 2 mins apart
• Cervical effacement 90%
• Head engaged, station +1
• Cervical dilation 6 cm
• Fetal heart sounds audible
• Maternal blood pressure 140/90 mmHg
• Maternal heart rate 98/min
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PLAN:
• Deliver the baby since patient in active labor
• I.V. hydralazine hydrochloride 5-10 mg every 15-20 minutes until BP under control
• No epidural (patient refused)
• Close monitoring, maternal vitals, progress of labor
• Oxygen if needed
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08:40 A.M
• 100% cervical effacement
• Fetal station +4
• Strong, frequent uterine contractions
• Stable CTG
• Maternal BP 130/90 mmHg
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• Heart rate 80/min
PLAN
• Stop hydralazine
• Support labor progression, deliver baby
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09:10 A.M
• Delivered baby boy
• Mother stable
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• No vaginal lacerations
Baby’s Nursing notes
09:11 A.M
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• APGAR 5
• Weight: 4.1kg
• Not crying, cyanosed
• Massaged and back slapped, crying started
• Kept on warmer
• Nasal suctioning done
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09:16 A.M
• APGAR 7
• Hypothermic & cyanosed
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PLAN: Immediate transfer of both mother and baby to hospital with NICU for:
• Neonatal resuscitation and premature neonatal care
• Complete examination by pediatrician
• Maternal risk factor management by obstetrician
• Counselling for next pregnancies
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Writing Task
Using the information in the case notes, write a letter of transfer to Queensland Royal Hospital where
Mrs. Smith and her newborn baby can be monitored and cared for by an obstetrician and pediatrician
respectively. Address the letter to the Admission Officer.
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• DO NOT use note form in the letter.
• Expand the case notes where relevant into full sentences.
• Use formal letter format.
The main part of the letter should be approximately 180-200 words long.
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Case Notes Study 2
WRITING SUB-TEST: MEDICINE

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Notes:
Assume today’s date is 19/01/2022.
You are a GP practising at Collin’s Clinical Center, and Mrs. Kathy Shawn is a new patient.
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PATIENT DETAILS:
Name: Kathy Jonnas Shawn
Age: 26 years
Marital Status: Married (04/04/2018)
Occupation: Sales clerk
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Husband: Jonnas Shawn
Husband’s Occupation: Civil engineer
Presenting Complaints (started 24 hours ago):

• G2 P0
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• In 20th week of gestation
• Dizziness, headache, nausea, vomiting
• Blurred vision
• Abdominal pain
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• Vaginal spotting
Past Antenatal Visit:

• 5th week of gestation (pregnancy confirmation - ultrasound and urine PT)
Counselled, aspirin 100 mg daily
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Weekly visits advised

• Lost to follow-up
Past Medical History:

• Intermittent Asthma (10/07/2014), Albuterol inhaler SOS
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Past Surgical History:

• Appendectomy (14/05/2012)
Past Gynecological and Obstetric History:

• Pelvic inflammatory disease (14/07/2013), completed 2 week antibiotic course
• First pregnancy ended in miscarriage,12 week gestation (02/07/2019) secondary to:
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○ Pre-eclampsia
Avg. BP throughout pregnancy 150/90 mmHg, pitting edema face and legs, proteinuria
Previous GP advised lifestyle modification and aspirin 100mg daily
○ Antiphospholipid syndrome (07/10/2019)
Diagnosed (after miscarriage) with ELISA positive for anti-cardiolipin antibodies
No treatment since asymptomatic status, counselling about next pregnancy
Allergies:
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• Dust and pollen
• Penicillin
Social History:
• Studied till middle school
• Smoker (10 cigs daily)
• Occasional crack and alcohol intake
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Family History:
• Mother diabetic, hypertensive
• 2 half sisters, unknown medical history
• Father died of pancreatic cancer 24 years back
Physical Examination:
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• Confused but oriented in person, place, time
• BMI 31 kg/m2
• BP 152/90 mmHg
• Pulse 90/ min
• RR 22/min
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• B/L pedal edema pitting type
• Facial puffiness, periorbital edema
• Mild RUQ abdominal tenderness
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Obstetric Examination:
• Fundal height 23cm
• Tender to deep palpation
• Fetal lie oblique
• Fetal heart sounds audible but faint
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Provisional Diagnosis: Pre-eclampsia
Plan
• Urgently refer patient to obstetrician for close monitoring & adequate blood pressure control to prevent
progression to eclampsia
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Writing Task
Using the information in the case notes, write a letter of referral to Dr Anita Arora, an obstetrician at
Melbourne Maternity Centre, East Melbourne 3007, for urgent management.
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Case Notes Study 3

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Notes:
You are a station house officer at Royal Adelaide Hospital and have been managing Mr. Peter Berry for the
past 6 months.
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Hospital: Royal Adelaide Hospital, Port Rd, Adelaide SA 5000, Australia
Date of Admission: 26/06/2021
Diagnosis: Traumatic head injury (RTA)
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Patient Details:
Name: Mr. Peter Berry
DOB: 26/03/1991 (30 yo)
Marital status: Single
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Occupation: Accountant
Next of Kin: Amelia Andy (55, mother)
Social Background:
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• Smokes 9 cigs daily

• Moderate alcohol consumption
• Frequent overspeeding fines
• Mother OT scrub nurse
• Father died of pancreatic cancer 4 years back
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26/06/2021
• Brought to emergency after severe automobile collision
• Primary and secondary trauma survey, FAST, CT head done
• Subdural hematoma, right femur fracture, initial resuscitation (ABCDE and IV 0.9% NaCl)
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28/06/2021
• Patient hemodynamically stable (bp 106/78 mmHg, pulse 90/min, afebrile, RR 22/min)
• Craniotomy & repair of femur fracture
• Patient vitally stable
• Not awaken from surgery
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01/07/2021
• Patient still non-responsive, vital functions normal (bp 100/80 mmHg, pulse 94/min, afebrile, RR 26/min)
• IV mannitol, IV broad spectrum antibiotics, IV fluids administered, supportive care, ICU monitoring
07/09/2021
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• Coma reversal, GCS 9, problems with speech, delirious state
• Baseline investigations sent, electrolyte abnormalities corrected, pain medications
11/10/2021
• ↑ GCS 13, oriented, alert, conscious
• Problems with speech and mobility
• Physical rehab & speech therapy started
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24/12/2021
• Social withdrawal, hopelessness, suicidal ideation
• Difficulty with speech reduced but need wheelchair assistance
• Mother requests transfer to mental health and rehab facility for better care
Plan:
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• Continue speech therapy and physical rehab
• Psych assessment for depression
• Counselling for social behavior (speeding, alcohol, smoking)
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Writing Task
Using the information in the case notes, you need to write a transfer letter to the director of Mary
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Curie Physical and Mental Health Rehabilitation Center, Mr. Edward Collins, to provide further care
for Mr. Peter Berry.

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The main part of the letter should be approximately 180-200 words long
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Case Notes Study 4

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Notes:
You are a venereal disease specialist working at the Department of Communicable Diseases, Australia. Today,
you examined Mr. Henry Mathews, referred by his GP, Dr. Kumar.
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Patient details:
Name: Henry Mathews
Age: 24 years
Occupation: Local club owner
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Address: 230 Spencer Street, West Melbourne
Next of kin: Bethany Mathews (28, sister)
Past medical history:

• ADHD (20th September 2002)
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• Mild meningococcal meningitis (12th August 2014)
• Essential hypertension (10th May 2017)
Past surgical history:

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• Laparoscopic varicocele repair (25th April 2017)
Family history:
• Father died of alcoholic liver disease 8 years back, was abusive, had multiple extramarital affairs
• Mother diabetic, caring, volunteer at local community service center
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• 3 siblings, patient is youngest.

• Lives with eldest sister who is homemaker
• Twin brother is engineer in China
Personal history:
• Heavy drinker, started after first break-up (July 2014)
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• 10-12 cigarettes per day for 15 years

• Occasional one-night stands, new relationship of 14 days
• No previous history of STDs
Medications:
• Hydrochlorothiazide 25 mg OD
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• Captopril 12.5 mg PRN (BP >140/90)

• Atorvastatin 10 mg HS
Allergies:
• Penicillin
• Metals
Reason for referral:
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• Complicated STD
25/01/2022
Presenting complaints:
• Rash on genitals, extremities, and trunk
• Fever, sore throat, headache, malaise
• Joint pain
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Examination findings:
• BP: 130/90 mmHgm Temp. 101F, Pulse: 90/min, RR: 18/min
• Maculopapular rash all over trunk and extremities including palms and soles (rash pinkish,
symmetrical, non-itchy)
• Flat, velvety, painless lesions on genitals
• Swollen painful, red knuckles
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Test results:
• CBC: Hb 10.5 g/dl, Hematocrit 31.5, Wbc 14,000/ mm3, Neutrophils 86%, Platelets 103,000/ mm3
• Rh Factor: neg
• HIV ELISA: neg
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• Hep B & C serology: neg
• Monospot: neg
• RPR: positive
• Dark field microscopy of condylomata: Treponema pallidum bacteria visible
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• Treponema pallidum particle agglutination (TPPA) test: positive
Diagnosis: Secondary syphilis
Treatment:
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• Tab. Doxycycline 100 mg BID for 14 days

• Tab. Paracetamol 1000 mg QID for fever, SOS for joint pain
• Avoid sexual contact until rash heals completely
• Report any severe, new-onset symptoms immediately
Plan:
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• Report local health department

• Update GP for
○ Proper follow-up
○ Safe sexual practise counselling (reinforcement)
○ Treatment compliance & long-term complications guidance
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○ Inform and assess all possible contacts maintaining confidentiality

○ Vaccination (hep B, C)
Writing Task
Using the information in the case notes, write an update letter regarding Mr. Mathews’ condition to
his general practitioner, Dr Aneel Kumar working at Melbourne City Clinic, 98 Brick Road, West Mel-
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bourne 3007.

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Case Notes Study 5

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Notes:
Mrs. Ruth James was brought to ED of a hospital in which you are Emergency Registrar.
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Patient’s Name: Mrs. Ruth James
DOB: 12/02/1986
Address: 256 Park Avenue, NY
Social Background: Married, works in an IT company as programmer
Family History:
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• Father diabetic
• Mother & sister asthmatic
Medical History:
• Asthma since 20 years of age (Salmeterol 50mcg PO inhaler BID)
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• No known drug allergies
25/07/2021
Subjective
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• Blunt injury isolated to face following fall from ladder when cleaning the ceiling
• loss of consciousness (5 mins)
• Oriented and conscious on admission
Objective:
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• Dish-face deformity, multiple lacerations

• Dropped upper jaw
• Profuse bleeding from nose and mouth
• Both nares obstructed, breathing from mouth with difficulty
• Periorbital oedema
• Vital Signs – BP- 130/100, HR- 86, RR- 12, Sats- 80 %
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• Eye movements and vision normal

• Facial examination
○ 3 cm laceration nasal bridge
○ 4cm laceration upper lip extending over face
○ Tenderness in frontal and maxillary sinus area bilaterally
○ Orbital margin tender
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○ Floating maxilla
• Intraoral examination
○ Malocclusion
○ Displaced both central incisors
○ Mandibular and ear examination: Normal bilaterally
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Investigations:
• CT Head (frontal contusion and haemorrhage)
• CT Facial bones (fractured pterygoid plate & orbital floor)
• GCS (normal)
• CBC, Coagulation and electrolytes (normal)
Assessment:
• Maxillary Fracture
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Plan
• Nasotracheal intubation over a flexible bronchoscope
• Control bleeding
• Ringer Lactate Infusion
• Augmentin 1.2g I.V., every 8 hourly
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• Urgent referral to surgeon - Restoration of functional occlusion, reconstruction of stable bony facial contour,
intermaxillary fixation for stabilization followed by rigid fixation of maxilla

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Writing Task
Write a letter to Dr. Thomas John Perkins, a maxillofacial surgeon in New York Medical Center,
Queens, NY, for urgent surgical management of the patient.
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Case Notes Study 6

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Notes:
You are a cardiologist at the Coronary Care Unit, Alaska Regional Hospital, United States, and the patient has
been admitted to the CCU.
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Today’s Date: 18/11/21
Date of Admission: 14/11/21
Patient Details:
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Name: Sabrina Jagosh
Gender: Female
Age: 53 years
Social History:
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• Widowed, Retired salesperson
• Has 1 adult son - lives abroad
• Smoking - 14/day
• Alcohol - 17 units/week
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Medical History:
• Has hyperlipidaemia and HTN -10 years- takes Rovista 20 mg HS and Atacand 10 mg OD
• Family medical history of HTN and T2DM
• Allergies: Penicillin and dust
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14/11/21
Subjective
• Reported to ED
• C/o left sided chest heaviness, pain radiating to left arm, jaw and epigastric region, heavy perspiration,
vomiting, and air hunger (since 15 mins)
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Objective
• Abdomen non-tender
• BP- 126/95, Pulse- 112/min, RR - 25 BMP, O2 Sat - 91%, Temp.- 37.4 C
Initial ED diagnosis: ? Myocardial infarction

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Management:
• Applied O2 10L via face mask
• Administered morphine IV
• Diagnostic workup
• ECG-prominent Q waves, T wave inversion
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• U/S Abd-NAD
• Shifted to CCU immediately, vomited while transfer
15/11/21
Subjective
• Chest pain increased
Objective
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• Speech- slurred
• GCS 15/15
Investigations:
• ECG repeated- ST elevation in leads I, aVL, V5, and V6
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Diagnosis: Anterior wall MI
Management Plan:
• Started O2 15 L/min, TPA therapy clopidogrel, aspirin 150 mg PO
• Requested echocardiography and CXR
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17/11/21
• Echo - anterior wall motion abnormality
• CXR-clear
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Subjective
• Chest pain mild
• SOB improved
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Objective
• Speech – normal
• Repeated ECG-prominent Q waves
Management:
• Continue medications and oxygen
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• Diet - low salt, low fat, low carb

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18/11/21
• Condition stable
• ECHO repeated: stable, EF >50%
• Pt requested to go home
• Plan to discharge today
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Discharge plan:
• Continue aspirin and clopidogrel for lifetime
• Continue Rovista 20 mg HS and Atacand 10 mg OD
• Regular walk for 15-30 mins/day
• Advice smoking and alcohol cessation
• Encourage DASH diet
• F/U after a week with repeat ECG
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Writing Task
Using the information in the case notes, write a discharge letter to the patient’s GP, informing him
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about her condition and further care needs. Address the letter to Mr. Qalab Abbas, GP, Private Clinic,
Debarr Road, Anchorage, Alaska, USA.

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Case Notes Study 7

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Notes:
You are a resident doctor working at Modbury Hospital, and one of your patients is being discharged today.
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Patient Details:
Name: Ms. Olivia Grace
DOB: 17/09/1988
Marital Status: Divorced
Address: Smart Rd, North Eastern Adelaide 5009, SA
Next of kin: Peter Grace (36, brother)
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Date Admitted: 17th Dec 2021 (7th hospital admission since diagnosis)
Date Discharged: 27th Dec 2021
Reason for Admission: Decompensated Schizophrenia

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• Diagnosed with schizophrenia 15/05/2015
• Drug induced movement disorder 08/06/2016
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Family history:
• Diabetic mother
• Hypertensive father, died 8 years ago of cardiovascular complication
• Maternal aunt suffers from schizophrenia
• 2 biological brothers
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• 1 half sister (maternal)
Social background:
• Got married in 2011
• Divorced in 2012 after diagnosis of schizophrenia
• No social circle
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• Limited family support (lives with brother)

• Living on disability allowance
• Heavy smoker (20 cigs daily)
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17/12/2021:
• Brought to emergency in combative state
• Actively hallucinating, paranoid (hostile towards brother and hospital staff)
• Refusal to eat and drink
• Brother informs treatment non-compliance
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• Admitted, strict monitoring protocol
• STAT IM Diazepam 10 mg with IM Haloperidol 10 mg,
• IV 0.9% NaCl with 5% dextrose water slow infusion over 24 hours
18/12/2021:
• Slight drowsy, talking irrelevantly, hallucinatory behavior
• Continue refusing oral food
• Started Risperidone 2 mg b.i.d, Procyclidine 5 mg b.i.d (reduce risk of EPS), Lorazepam 1 mg HS
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20/12/2021:
• No Improvement
• Increased Risperidone 2 mg t.i.d
• IV fluids continued
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22/12/2021:
• Decreased paranoia but reports hallucination
• Ready to eat cake and sips of juice
• IV fluids stopped
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25/12/2021:
• Condition improving, no anger, aggression, ideas of persecution, ↓hallucinations
• Eating and drinking well & sleeping well
• Extrapyramidal symptoms (EPS) like muscular rigidity, spasms, tremors - Nil
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• Started on fortnightly IM inj. Clopixol depot 200 mg (due to history of noncompliance), tab.
Procyclidine 5 mg bid
27/12/2021:
• Condition stage
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• Discharged
• Can follow commands but speech still irrelevant
• Denying delusions and hallucinations
• Sleep and appetite fine
Discharge Plan:
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• Fortnightly IM inj. Clopixol depot 200 mg (next due on 09/01/2022)

• Tab. Procyclidine 5 mg bid
• Follow up with her psychiatrist
○ rehabilitation
○ psychosocial skills training
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○ re-emphasise treatment compliance
Writing Task
Using the information in the case notes, you need to write a discharge letter to Ms. Olivia Grace’s
psychiatrist, Dr. Mark Gregory, 127/55 Modbury Rd, North Eastern Adelaide 6007, SA.
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Case Notes Study 8

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Notes:
You are a consultant rheumatologist at Royal Melbourne Hospital, 300 Grattan St, Parkville VIC 3050, Austra-
lia. Ms. Bisma Saleem was referred to you by her GP.
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Patient details:
Name: Ms. Bisma Saleem
Age: 17 years
Occupation: High School Student
Next of kin: Saleem Merchant (40, father)
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Father’s occupation: Coal mine engineer
Ethnicity: Asian (immigrant)
Date seen: 14/01/2022

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• Chronic anemia, recognized since menarche at 9 years age, twice blood transfusions (2014, 2016)
Family history:
• Mother: 38, from Bangladesh, suffers from Hashimoto’s thyroiditis
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• Father: 40, from Pakistan, no known co-morbids

• Parents immigrated to Australia 6 years back
• 1 younger sibling, sister, 6 years old, congenital hypothyroidism
Social factors:
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• No social circle
• Does not drink or smoke
• Not sexually active
Past medications:
• Acetaminophen
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• Antibiotics
• Antiallergics
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Current appointment (14/01/22)
Presenting complaints:
• Facial rash
• Recurrent oral ulcers
• Chronic low-grade fever
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• Weight loss of 4-kg in 2 months
• Fatigue, lethargy
• Frothy, foul-smelling urine
• 2 episodes of tonic-clonic seizures (in last 24 hours)
• Body aches
Examination:
• BP: 97/74 mmHg
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• Pulse: 102/ min
• Temp. 100 F
• BMI: 18 kg/m2
• Temporal alopecia
• Butterfly rash on cheeks
• Multiple oral ulcers
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• Cold extremities, with bluish distal digits
• Mild PIP, MCP, and wrist joint swelling, tenderness, redness
Laboratory investigation findings:

• Hb 10.3 mg/dl, WBC 7000/mm3, plt 102,000/mm3
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• Direct Coombs Test +ve
• Antinuclear antibody (ANA) +ve
• Anti-dsDNA +ve
• Cr 1.3 mg/dl
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• Spot protein/spot creatinine ratio 1 g/ day

• WBC casts on urine DR
• MRI plain brain - awaited
• EEG - awaited
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Working diagnosis: Systemic lupus erythematosus (SLE)
Plan:
• Hydroxychloroquine 200 mg daily
• Ibuprofen 400 mg TID
• Prednisone 10 mg OD
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• Assess clinical response in 7 days

• Arrange arthrocentesis & ECHO
• Need for LP?
• Regular monitoring for electrolytes, seizures
• Inform referring GP
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• Counsel family
Writing Task
Using the information in the case notes, write an update letter to Dr. Marry Elsworth, Ms. Bisma Sal-
eem’s GP, practicing at New Century Medical Surgery, 94 Clemency Road, East Melbourne.
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Case Notes Study 9

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Notes:
You are a psychiatrist, practising at Mental Health Center, Queensland, and Aron has been your regular patient.
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Office: Mental Health Center, Herston QLD 4006, Australia.
Patient Details:
Name: Mr. Aron Steve
DOB: 07/10/1996 (25 yrs)
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Occupation: Chemistry lab assistant
Education: High school diploma in chemistry
Next of kin: Amy, Steve (47, mother)

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• Bronchitis (15/09/19)
Past Surgical History:

• Appendectomy (14/05/2012)
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Social Background:
• Only child, raised by single mother
• Mother hemiplegic, struggled with heroin addiction
• Father left his mother before his birth
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• Moderate smoker
• Consuming 4-5 beer cans daily
Psychiatric Background:
06/07/2002
• Diagnosis: Dyslexia (Sx learning difficulty, problems reading, severe crying spells, isolated behavior)
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• Referred to specialized school
17/07/2016
• Brought to clinic by mother with low mood, decreased interest in all activities, social
withdrawal,anorexia, insomnia, feelings of guilt and worthlessness, HAM-D score 18
• Diagnosis: Moderate depression with low suicide risk
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• Treated as outpatient with Escitalopram 10mg OD, Lorazepam 0.5 mg HS

• Follow up 2 weeks
18/09/2016
• Remission achieved, HAM-D score 5
• Advised to continue Escitalopram 10 mg for 6 months
19/09/2017
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• Brought to emergency with suicidal ideation, anhedonia, decreased attention and concentration
• O/E: suicidal risk high & admitted
• Tab. Escitalopram 10 mg OD (increased to 20mg after 4 days), Alprazolam 0.25 HS
• 28/09/2017: Discharged stable, low suicidal risk. Advised Escitalopram 10 mg OD & regular counselling
16/06/2021
• Presented with repetitive hand washing (20-30 times/day), frequent unavoidable thoughts regarding
contamination, severe anxiety, problems at job
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• Diagnosed with Obsessive Compulsive Disorder (OCD)
• Advised Tab. Sertraline 25mg OD, follow-up 2 weeks
02/07/2021:
• 1st follow-up, decreased thoughts & frequency but repetitive hand washing persists
• Advised Tab. Sertraline 50 mg OD, follow-up 1 month
ar
Today (02/08/21):
• Obsessions controlled slightly
• Compulsions exist with same intensity
• Severe anxiety
m
• Reduced functionality at work
Plan:
• Increase Tab. Sertraline to 100 mg OD & Tab. Alprazolam 0.5mg HS
ch
• Referral to psychologist for CBT (evidence of greater benefit with combination CBT and drug treatment)
• Follow up 1 month
en
Writing Task
Using the information in the case notes, you need to write a referral letter to the psychologist to
administer CBT and address psychological conflicts. Address the letter to Ms. Julia Wilson,
New Horizon Counselling, 288 Herston Rd, QLD.
ub

ed
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Case Notes Study 10

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Notes:
You are a GP working at Newton Medical Practice and have been managing Ms. Beatrice Angel
for the past 2 years.
k.c
Today’s Date: 21st Dec 2021
Patient Details:
Name: Ms. Beatrice Angel
Age: 60
ar
Marital status: Widow
Next of kin: Elma Wilson (55, sister)
Diagnosis: Type 2 Diabetes Mellitus (poorly controlled)

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Medical History:
• Essential hypertension (09/06/2017)
• Hypercholesterolemia (3 years)
• Uncontrolled type II DM (2 years)
ch
• MI (02/10/2020)
Regular Medications:
• Losartan 50 mg o.d
• Atorvastatin 10 mg h.s
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• Metformin 500 t.i.d
Social Background:
• Retired clerk, no children
• No social support, Lives in old age home
• Enjoys reading books
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• Sedentary lifestyle, BMI 31 (obese, 130 kg)

• Smokes 20 cigarettes per day, Social drinker
Medical Background:
12/11/2019
• Presented with polyphagia, polyuria, fatigue, and hypertension, lethargy.
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• FBS 7.2 mmol/l, HbA1c 7%

• Diagnosed with Type II DM
• Advised lifestyle modification, stop smoking, SMBG
19/11/2019
• Uncontrolled BG at follow up
• Non-compliant to treatment
• Advised Metformin 500 b.i.d.
• Emphasised need for regular medicine intake, lifestyle modification & stop smoking
om
02/10/2020
• Admitted: MI (ECG ST elevation, HbA1c 6.7%)
• Treatment: PCI, Aspirin 325 mg STAT
• Discharged on 12/10/2020 stable, HbA1c 5.9%
11/12/2021
• Admitted HHS (glucose 30 mmol/L, serum osmolarity 340 mOsm/kg)
k.c
• Management: IV fluids, electrolyte replacement, insulin therapy (0.1 units per kg i.v bolus then
0.1 units per kg/hr till bg within range)
• Discharged on 17/12/2021 with stable HbA1c 6.1%
• Refused insulin (↑ Metformin 500 t.i.d)
21/12/2021
ar
• Signs of early Rt foot infection (fever, localised swelling, redness, and pain)
• Still non-compliant - medicine & recommended lifestyle modification
Plan:
• Cephalexin 500mg PO b.i.d, & Paracetamol 1000mg P.O q4hr for fever
m
• Referral to endocrinologist for management of uncontrolled BG and related complications
ch
Writing Task
Using the information in the case notes, you need to write a referral letter to the
endocrinologist. Address the letter to Mr. Jack Stevens, New Horizon Medical Centre,
en
288 Herston Rd, QLD.

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Medicine Writing Practice for
Nursing
edubenchmark.com
Case Notes Study 1
WRITING SUB-TEST: NURSING

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Notes:
Ms. Tracy Ryan, a female patient, shifted to the post anesthesia care unit of James Cook University
Hospital, Marton Rd, Middlesbrough TS4 3BW, UK, after having abdominal exploration surgery.
k.c
You are the PACU nurse. Read the following case notes, and then complete the writing task below.
Patient’s info:
Name: Tracy Ryan
DOB: 21-02-1958
Marital Status: Married, 2 daughters
ar
Next of Kin: Husband, 50 yo, Engineer
Family History:
• Mother has rheumatoid arthritis
• father has hypertension & moderate aortic stenosis
m
Social History:
• Secretary in marketing company
• No drinking or smoking
ch
Medical History: NAD
Surgical hx:
• Appendectomy 3 years ago
en
• 2 cesarean deliveries
Admission day: 20-09-2021
Dx: Adhesive intestinal obstruction

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21-09-2021- Surgery Day
Surgery events:
Pt. had abdominal exploration following clinical & radiological suspicion of intestinal obstruction
• Received general anesthesia, ETT tube & +ve pressure ventilation
• Started laparoscopically but shifted to open after uncontrolled bleeding
ed
• Pt. lost a lot of blood intraoperatively, received 2 units packed RBCs & 1 unit plasma
• Incision midline, closed with staples not sutures
PACU nursing notes after Pt arrived:
• Vitals stable, BP 125/66 HR 89 Spo2 98
• Administered 1000 ml ringer solution IV
• Upon waking, complained of little pain, doctor ordered 1000 mg paracetamol IV & Ketorolac ampule IM
• Stayed in PACU for 1 hour following surgery
om
• Fully conscious, talking, will be transferred to general surgery ward
• Pt. has urinary catheter attached to urine bag, central venous catheter for administration of drugs & fluids, 2
drains from abdomen attached to collecting bags
Nursing instructions in ward:

• Monitor patient’s vital signs, report to dr. if any hypotension or tachycardia or fever
• Keep incision sterilized & dry
• Monitor drains regularly, alert dr. if saw unusual amount of blood
k.c
• CVC must be kept sterilized, change dressing daily
• Urine output should be calculated every 12 hours, if low, report to dr.
• IV ringer solution 10 ml/kg slowly over 24h
• Ceftriaxone 500 IV every 12 h after sensitivity test
• Alert dr. if noticed any respiratory distress
• Continue wearing compression elastic stocking
ar
Writing Task
m
Using the Information in the case notes above, write a transfer letter to general surgery ward residen-
tial nurse, Ms. Daisy Anderson, summarizing surgery notes, and postoperative nursing instructions.

ch

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Case Notes Study 2

om
Notes:
Alex Davies, a male child, was admitted to the pediatric oncology department. You are the pediatric residential
nurse. Read the following case notes, and then complete the writing task below.
k.c
Patient’s info:
Name: Alex Davies
DOB: 01-07-2014, 8yo
Next of Kin: Mother 33 yrs, staying with him in hospital
Family History: Father asthmatic
ar
Social History: Preschool child, lives with his parents, no siblings
Admission day: 11-12-2021
Medical History: Recurrent chest infections, Stunted growth in early childhood
Surgical hx: No surgical hx
m
12-12-2021
Hospital: Bristol Royal Hospital for Children, Upper Maudlin St, Bristol BS2 8BJ, United Kingdom
Pt. admitted yesterday to pediatric oncology department to complete diagnosis of type of leukemia &
start chemotherapy protocol
ch
Patient’s medical details:

• Last week severe paleness, paediatrician requested CBC, Hb was 5 gm/dl
• Admitted to hospital, received 1 unit packed RBCs
• Biopsy procedure done yesterday under sedation
en
• Needle puncture sites in iliac bone & humerus
Dx: Acute lymphocytic leukemia
Nursing management:
• Pt psychologically affected, scared of nurses & needles
ub
• Cries & shouts vigorously if any nurse comes near him

• Trials to familiarize with child, telling stories, offering toys
• Starts to show purpura & petechiae
• Doctor ordered CBC to check platelets, platelet count 6000, doctor ordered 4 units of platelets consecutively
• Pt. started to be feverish, temp. 38°C
• Dressing over biopsy punctures sterilized & changed
ed
• Mother said low urine output, diapers were put on to roughly estimate urine amount
Nursing instructions for the next shift:
• Familiarize with Pt, he likes being told stories
• Report to dr. if feverish
• Provide healthy diet with vegetables & fruits, also white easily digested protein such as poultry
• Chemo to be given in next few hours, make sure to report any irregular signs to dr.
om
• Monitor amount of full diapers per day, report to dr.
• Paracetamol suppository every 12 hrs with mother’s help
• IV ringer solution 6 ml/kg slowly over 24 h for following day
Writing Task
k.c
Using the Information in the case notes above, write an update letter to the paediatric residential
nurse in the following shift explaining the patient’s condition and further management instructions.
Address the letter to Ms. Jackie Wilson.

ar
m
ch
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Case Notes Study 3

om
Notes:
Mr. Nagib Smith, a male patient in ICU of Croydon University Hospital, 530 London Rd, Thornton Heath
CR7 7YE, UK. You are the ICU residential nurse. Read the following case notes, and then complete the
k.c
writing task below.
Patient’s Info:
Name: Nagib Smith
DOB: 28-06-1952
Marital Status: Married, no kids
ar
Next of Kin: Wife, 52 yo, teacher
Family History: Brother has CRF, mother diabetic
Social History: Plumber, heavy smoker & occasional alcohol intake
Medical History:
m
• Diabetic, unstable, on biguanides for 3 years
• Dx with hepatoma a month ago, on chemotherapy after liver resection surgery to remove tumor
• Smokes one pack per day
• Tonsillectomy as a child
ch
• Inguinal herniorrhaphy 3 years ago
Admission: 14-01-2022
20-01-2022
en
Pt. in ICU for 6 days now
Dx: Liver cancer metastasized to both lungs, confirmed by PET CT scan
Patient’s Medical Details:

• Has multiple metastatic pulmonary nodules
ub
• Pt. had hypoglycemic coma today

• Consciousness lost, even after raising blood glucose level
• Doctor decided to intubate till pt. gained full consciousness to avoid aspiration
Intubation:
• ETT inserted, pt. GCS 3
ed
• Vitals stable, BP 108/61 HR 100 Spo2 95 after intubation

• Ventilator tube attached for +ve pressure ventilation
ICU Care:
• Pt. bathed, position changed every 3 hours
• ETT tube suctioned repetitively, pt. has a lot of secretions
• Pt. has urinary catheter, central venous catheter, ETT tube and nasogastric tube
om
Nursing Management:
• Continue suctioning ETT tube to avoid tube blockage
• Pt. should be 45° up to enhance lung condition
• Report to dr. if any improvement in consciousness level noticed
• Care of diapers, clean thoroughly to avoid bed sores
• Monitor vital signs, report to dr. if any arrhythmia or hypotension occurs
• Calculate UOP as pt. is oliguric, might require dialysis
• IV ringer solution 10 ml/kg slowly over 24h, unless patient becomes anuric
k.c
Writing Task
Using the Information in the case notes above, write an update letter to the patient’s PCP explaining
ar
the patient’s condition and nursing management instructions. Address the letter to Dr. Andrea Frank-
lin at 3 Strouts Pl, London E2 7QU, UK.

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ch
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Case Notes Study 4

om
Notes:
Ms. Layla Taylor is a female patient in the general surgery ward at Croydon University Hospital, Mayday
House, London Road, Thornton Heath, UK. You are the ward residential nurse. Read the following case
k.c
notes, and then complete the writing task below.
Patient Details:
Name: Layla Taylor
DOB: 21-11-1987
Age: 33 yrs
ar
Marital Status: Divorced, no kids
Next of Kin: Brother, 40 yrs
Family History: Father has third degree heart block, mother has kyphoscoliosis
Social History: Modelling in fashion shows
Medical History: Bronchial asthma & hyperthyroidism
m
Surgical History: NAD
Admission:
20-11-2021
ch
Pt. arrived at ward after having total thyroidectomy due to clinical, laboratory, radiological diagnosis of
multinodular goiter
Surgery Events:
• Surgery performed under general anesthesia, airway easy, no complication
en
• Goiter huge, lump in front of patient’s neck

• Surgery lasted 2 hours, dissection difficult, took time to resect both thyroid lobes, no bleeding
• Incision transverse lower midcervical, about 10 cm long
• Recovered from anesthesia
• In PACU, pt. complained of pain, received paracetamol IV & Nalbuphine 10mg IV
• No complications, pt. transferred to ward
ub
Ward Nursing Instructions:

• Monitor patient closely, be careful of any respiratory complaints
• Blood pressure, pulse, RR & temperature should be measured every hour
• Sterilize incision, change dressing twice per day
• Surgeon inserted one small drain, check regularly for bleeding
ed
• Encourage oral fluids within 3 hours of surgery
• IV ringer solution 3 ml/kg slowly over 24h
• Amoxicillin Clavulunic acid 500 IV every 12h after sensitivity test
At 6 pm (Same Day)
om
• Pt. coughing, repetitively
• Nurse prepared bronchodilator inhalation session & notified surgeon for possible asthma
• Cough became worse, turned to abnormal high pitched wheezy sound, stridor
• Pt. struggling to inhale, kept pointing to her neck
• Drains clear, no bleeding
Plan:
• Oxygen mask, to alleviate respiratory distress
k.c
• Urgent referral to otolaryngologist for urgent tracheostomy procedure
Writing Task
ar
Using the Information in the case notes above, write an urgent referral letter to the otolaryngologist at
the same hospital, explaining case circumstances, and asking for immediate assistance. Address the
letter to Dr. Sara Liam.

m
ch
en
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Case Notes Study 5

om
Notes:
Ms. Donna Paul is a female resident (for 2 years) in Whitebourne Age Care Home at Burleigh Rd, Frimley,
Camberley GU16 7EP, UK. You are the residential nurse. Read the following case notes, and then complete
k.c
the writing task below.
Patient Details:
Name: Donna Paul
DOB: January 21, 1952
Age: 69 yrs
ar
Marital Status: Widow, 1 son
Next of Kin: Son 30 yrs, owner of car shop
Family History: Brother had stroke
Social History: Retired librarian, not smoker
Son rarely visits or calls. Pt. had huge fight on phone with him begging him to come see her a week ago.
m
Medical History:
• HTN (2010)
• IHD (2015)
ch
• MI (2021)
• Fallopian tube resection after ectopic pregnancy
• Cesarean delivery
20-01-2022
en
• Pt. had cardiac catheterization with 2 bare-metal stents insertion on 17/01/2022

• Returned to aged care facility this morning
Nursing Instructions:
• Check HR, BP hourly, notify doctor if BP above 140/90 or if HR above 100
• lasix 20 mg twice daily, Carvedilol 20 mg twice daily, Clopidogrel 75 mg twice daily all PO
ub
• Inquire pt. regularly about chest pain, alert doctor if any

• Encourage ambulation as tolerated
• Advice pt. to take oral fluids hourly & avoid ↑ blood viscosity
ed
Nursing Notes:
• Pt. looks depressed, didn’t want to talk to her favorite nurses
• Preferred staying in bed, unwilling to walk
• Stays awake even late at night
om
21-01-2022 (8am)
• Pt. shaking, crying, urinated in bed, bloody urine

• Nose bleed stained pillow
• Empty alcohol bottle by her side
• Clopidogrel drug bottle empty
• Nurse talked to pt, trying to calm her, get to know what happened
• Pt. admitted mixing alcohol with drugs, taking overdose of Clopidogrel to get her son to visit her
k.c
• Pt. threatened to do it again, shouting at nurse to call her son
• Nurse called EMS summarizing patient’s medical condition & incident – urgent transfer to ED decided
Dx: Attempted suicide with overdose of blood thinner medication
ar
Writing Task
Using the Information in the case notes above, write an urgent referral letter to emergency physician
Dr. Ahmed Nour at Frimley Park Hospital, Portsmouth Rd, Frimley, Camberley GU16 7UJ, United
m
Kingdom, requesting the patient’s medical and psychological management.

ch
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Case Notes Study 6

om
Notes:
You are the ward residential nurse at Gartnavel General Hospital, 1053 Great Western Rd, Glasgow G12 0YN,
UK.Ms. Scarlet Wilson, a female patient was admitted in the vascular surgery. Read the following case notes,
k.c
and then complete the writing task below.
Patient Details:
Name: Scarlet Wilson
DOB: 01-04-1989
Marital Status: Married, 3 kids
ar
Next of Kin: Husband, 36 yrs, Lawyer
Family History: Mother had varicose veins, father has Behcet’s disease
Social History: Stay at home mother
Medical History:
m
• Preeclampsia in last pregnancy
• Varicose veins, failed medical treatments
• DVT 6 months ago, on blood thinner (warfarin)
ch
Surgical History: 3 cesarean deliveries, last 8 months ago
Date of Admission
26-01-2022: Surgery same day
en
Surgery Events:
• Pt. had stripping of varicose vein
• Surgery done under spinal anesthesia
• Lasted 90 min.
• Pt. stopped taking warfarin 1 week before surgery, doctor expected bleeding, didn’t happen
• Uneventful, no complications
ub
• Pt. transferred to PACU then ward

ed
Ward Nursing Management:
• Pt. has high risk for DVT & pulmonary embolism, monitor vitals, awareness level & if chest pain occurred
• Hydrated pt, 10 ml/kg IV fluids per day + oral fluid intake
• PCA connected for analgesia over next 24 hours
• Dressing changed once on night of surgery, wound sterilized with betadine
om
• Pt. recovering well, no visible complications, minimal risk
• Discharge planned 27-01-2022
Discharge Plan:
• Advice pt. to get enough rest & sleep
• Wear tight bandage first 4 days post surgery
• No bathing for first week, keep tight bandage dry & clean
• Ketorolac IM injection/ 12 h for first 3 days
k.c
• Try walking slowly at day 6 post surgery, stop walking if severe pain or bleeding
• Resume Warfarin 3 days after surgery, to avoid bleeding risk
• Legs elevated on pillow above heart level, as many hours as possible to reduce bruising
• Usual diet, protein to enhance recovery, fresh fruits & vegetables
• Return to dr. after 7 days, for incision recheck & medications adjustment
ar
Writing Task
m
Using the Information in the case notes above, write a discharge letter to home care nurse
Ms. Alberta Allen, summarizing surgery notes, and providing home nursing instructions.

ch
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Case Notes Study 7

om
Notes:
Tom Johnson, a male child, was admitted to the pediatric surgery department at Royal Manchester Children’s
Hospital, Oxford Rd, Manchester M13 9WL, UK. You are the pediatric residential nurse. Read the following
k.c
case notes, and then complete the writing task below.
Patient’s Info:
Name: Tom Johnson
DOB: 04-10-2021
Next of Kin: Mother (22 yrs )
ar
Family History: Mother has DM type 1 (on insulin)
Admission Day: 10-02-2022
Medical hx: NAD
Diagnosis: Bilateral undescended testicles, scheduled for bilateral orchiopexy surgery

m
10-02-2022
Admitted to hospital with his mother, scheduled to have surgery next day
ch
Patient’s Medical Details:

• Healthy breastfed 4 month old baby
• Condition diagnosed by baby’s pediatrician on regular checkup
• Testicles can be felt in baby’s abdomen on palpation
• Xray & MRI abdomen done to confirm presence & site of testicles
en
• Scheduled operation to preserve future fertility & avoid cancer risk
11-02-2022 (Surgery day)

• Mother withheld breast milk for 4 hours to complete pre anesthesia fasting period
• Baby subjected to general anesthesia with spontaneous ventilation
• 2 bilateral small groin incisions made, surgery lasted 80 min.
ub
• Baby awakened, no complications, shifted to PACU then to ward

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Ward Nursing Management:
• Baby should resume breastfeeding 2 hours after end of surgery
• Incision care: Keep dry & sterilized, change dressing regularly as incision can get contaminated with
baby’s stool or urine
• Care of mother’s blood sugar insulin intake, as breast feeding might cause hypoglycemia which would
om
exaggerate if taking regular insulin
• Give Amoxicillin- Clavulanic 250 mg twice daily IV
• Paracetamol oral suspension, 2 ml every 8h for pain
• Discharge planned 12-02-2022
• R/V 7 days for incision checking
Nursing Instructions Post Discharge:

• Change dressing as soon as it gets wet, teach mother how to do it, use betadine
k.c
• Support mother’s breastfeeding, teach her different breast-feeding positions
• Encourage mother to eat healthy nutritious food to ensure quality breast milk for baby
• Keep an eye on mother’s medical condition, advice regular blood glucose checks, teach possible
hypoglycemia signs
• Instruct mother to monitor baby’s temperature
• Keep baby hydrated, make sure diapers filled with urine
ar
Writing Task
m
Using the Information in the case notes above, write a discharge letter to the pediatric community
health nurse explaining the patient’s & mother’s medical condition & nursing management instruc-
tions. Address the letter to Ms. Lora Wilson.
ch

en
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Case Notes Study 8

om
Notes:
Mr. Damian Barnes , a male patient in the ICU of Royal Hospital For Neuro-Disabilities, West Hill, London
SW15 3SW, UK, where you are the ICU residential nurse.
k.c
Patient’s Info:
Name: Damian Barnes
DOB: 28-06-1962
Marital Status: Widowed, 2 sons
Next of Kin: Son, 30 yrs, lab. technician
ar
Family History: Father died of hemorrhagic stroke, brother ankylosing spondylitis
Social History: Teacher, smoker (10 cig/d)
Medical History:
• HTN since 2013
m
• Type 2 DM since 2010
• Dyslipedemia & atherosclerosis
Surgical hx:
ch
• Lt. diabetic foot amputation 2018

• Inguinal herniorrhaphy 2005
04-01-2022
Pt. admitted to ICU 11 days ago for malignant hypertension control, developed massive hemorrhagic stroke
en
afterwards
Medical Details:
• On admission, pt. fully conscious, aware to time, place & person
• BP 190/120 HR 100
• Pt. developed pulmonary edema, dr. started lasix infusion
ub
• Pt. received nitroprusside sodium IV infusion at rate 10 mcg/kg/min

• Pt. Confused, stuttering, disturbed consciousness level
• CT brain showed massive hemorrhagic stroke
• Neurosurgery consulted, no benefit from surgery, patient’s condition won’t improve
• Pt. Intubated & ventilated, GCS 4
ed
16-01-2022
• Pt. transferred to OR for scheduled tracheostomy operation as pt. expected to stay ventilated in
foreseeable future
• Operation done, pt. returned to ICU
om
ICU Nursing instructions:
• Urgently page ENT surgeon if noticed any blood in or around tracheostomy tube
• Suction via tracheostomy tube carefully, to avoid injury & bleeding
• Monitor patient’s respiration & ventilation, if any abnormality, tracheostomy tube to be unsealed
• Provide hourly nasogastric tube nutrition, rest 8 hours at night
• Head elevation 45° up to decrease possible rebleeding
• BP should be maintained b/w 120/60 & 150/70
• Regularly change patient’s position, to avoid bed sores
k.c
• Check bl. glucose level hourly, stop insulin infusion if blood glucose less than 300
• Monitor pt. consciousness level, notify doctor with any changes
• Check UOP every 12h, check urine catheter for color of urine
• Pt. has recently inserted CVC catheter, change dressing & sterilize every 12h
• Fluids, IV ringer solution 12 ml/kg slowly over 24h
ar
Writing Task
Using the Information in the case notes above, write an update letter to the patient’s community
m
health nurse explaining the patient’s current condition and nursing management. Address the letter to
Ms. Nouran Ali at St Magnus House, Lower Thames St, London EC3R 6HD, UK.

ch

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Case Notes Study 9

om
Notes:
You are a student health nurse at Oswald Community College, Texas, USA.
k.c
Today’s date: 25th January 2012
Name: Nathalie Wiggins
Age: 24 years
Gender: Female
Diagnosis: Suicidal ideation
Place of birth: Haiti
ar
Status: Nursing College student (yr. 1)
Social History:
• Immigrated to US-December 2012 (student visa)
• Has few friends
m
• Introvert nature
• Victim of racial discrimination
• Lives in university hostel (off campus)
• Shares room with 3 people
ch
• Part-time waitress (local café)
Educational History:
• Joined nursing course by force (parental pressure)
• Interests: fashion designing
en
• Last CGPA 2.0 (failed few subjects)

• Flunked the mid-semester OSCE
• Can’t concentrate on studies
Family History:
• Eldest child (has 3 younger brothers)
ub
• Paternal aunts- Depression

• Grandmother-Anxiety disorder
• Grandfather-committed suicide
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Current Medical History
14th July 2012-10:00
• Received at the clinic after exam
• C/O fear of failure in the exam
• Crying, anxious, fearful, paranoid
om
• Cannot go to the job (taken leaves for 15 days)
Advised: Stress management techniques
25th July 2012-9:00 pm

• Received in clinic
• Accompanied by roommate-found her with rat killer
• C/O severe distress, desire to kill herself (failed in final exams)
k.c
• Can’t manage stress
• Smokes cocaine cigarettes (excessive)
• Hasn’t alked to family - past 3 months
• Bunks university classes
• Lacerations on B/L arms (blade cuts)
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Plan
• Arrange immediate psychiatric management
• Inform parents
m
Writing Task:
Using the information given in the case notes, write an urgent referral letter to Dr. Lamis Beshir,
ch
Psychiatrist and Mental Health Counsellor, Oswald psychiatric hospital, Texas, USA, requesting
emergency psychiatric management.

en
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Case Notes Study 10
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Notes:
You are a nurse in charge at Bloomberg Home Age Care agency staying with the patient during his hospital
admission. The patient is now shifting back to the old age care home.
k.c
Today’s date: 16th November 2021
Name: Giuseppe Matteo
Gender: Male
DOB: 25/08/1950
Age: 71 years
ar
DOA: 15th November 2012
Diagnosis: End-Stage Renal Disease (ESRD), mild dementia, Rt Lobar pneumonia
Place of birth: Italy
Social History:
m
• Lives at the old age care home
• Difficulty speaking English
• Wife-Maria (64 years)-lives in her own apartment
• One son, Giovanni, a plumber (occasionally visits)
ch
Medical History:
• H/O ESRD 5 years
• Dialysis (twice a week)
• Frequent breathing issues-on 2L oxygen (NP)
en
• Medication non-compliance
Family History:
• T2DM-mother and sister
• CRF caused father’s death
• Death of younger sister-RTA
ub
• Death of younger brother-Suicide

• Rheumatoid arthritis-wife (9 years)
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Recent Nursing Notes
15th November 2021 (6:00 pm)
• Arrived at an emergency-Resuscitation unit from old age care center
• Severe SOB and agitation
• GCS 13/15
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• BP 160/100 mm Hg, HR 110 b/min, T 36.8 C, O2Sat 81%
• ABGs stat-revealed hypercapnia-respiratory acidosis
• ECG done-sinus tachycardia
• Pt kept CBR
• Foley catheter inserted
• Dialysis begun
• Intubation done-Mechanical ventilator attached (full support)
• Pt is sedated and relaxed
k.c
• Shifted to ICU
16th November 2021 (6:35 am)

• ICU physician rounds done
• ABGs improved
• Extubated and breathing via BIPAP
ar
• NG feed 10 ml/h
• Pt is discharged today
Discharge Plan
• Shift pt. back to old age home
m
• Arrange Oxygen therapy and BIPAP machine
• NG feed (Glucerna) 100 ml q6h
• BGL premeal
• Dialysis (twice a week)
ch
• Involve physiotherapist (chest physiotherapy)

• ROM q4h
• Positioning and back care q2h to avoid pressure ulcers
• Toileting assistance
• Hygiene care
en
Writing Task
Using the information given in the case notes, write a discharge letter to Ms. Shenaz Abraham,
home care supervisor, updating her about patient’s condition and home care requirements.
ub
Address the letter to Ms. Shenaz Abraham, Bloomberg Home care agency, Chapel Hill, NC.

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Case Notes Study 1
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Notes:
You are a GP working at Newton Medical Practice and have been managing Ms. Beatrice Angel for the
past 2 years for multiple medical conditions.
k.c
Office: Newton Medical Practice, 16-18 Newton Rd, Melbourne.
Today’s Date: 21st Dec 2021
Patient Details:
Name: Ms. Beatrice Angel
Age: 60
Marital status: Widow
ar
Next of kin: Elma Wilson (55, sister)
Diagnosis: Type 2 Diabetes Mellitus, IHD

m
• Essential hypertension (09/06/2017), Losartan 50 mg o.d
• Hypercholesterolemia (3 years), Atorvastatin 10 mg h.s
• Uncontrolled type II DM (2 years), Metformin 500 t.i.d
ch
• MI (02/10/2020), Aspirin 300 mg o.d
Social Background:
• Retired clerk, lives in old age home
• Adopted stray dog 2 years back
• 2-3 friends, not close enough
en
• No children
• Sedentary lifestyle, BMI 31 (obese, 130 kg)
• Social drinker
• Smoker (20 cigs daily- 15 years)
ub
Medical Background:
12/11/2019
Presented with polyphagia, polyuria, fatigue, and hypertension, lethargy. FBS 7.2 mmol/l, HbA1c 7%,
TC 250 mg/dl
Diagnosed with Type II DM
Advised lifestyle modification, SMBG
ed
Uncontrolled BG at follow ups (19/11/2019), (02/12/2019), (10/01/2020)
Non-compliant to treatment
Advised Metformin 500 b.i.d.
Emphasised need for regular medicine intake, lifestyle modification, stop smoking
om
04/04/2020
Admitted: moderate depressive episode, BG still high.
Given counseling
Refused drug treatment
Referral to clinical psychologist
Discharged on 06/04/2020: LAMA
02/10/2020
k.c
Admitted: MI (ECG ST elevation, HbA1c 6.7%)
Treatment: PCI, Aspirin 325 mg STAT
Discharged on 12/10/2020 stable, HbA1c 5.9%
11/12/2021
Admitted HHS (glucose 30 mmol/L, serum osmolarity 340 mOsm/kg) IV fluids, electrolyte replacement,
ar
insulin therapy (0.1 units per kg i.v bolus then 0.1 units per kg/hr till bg within range)
Discharged on 17/12/2021 stable HbA1c 6.1%,
Discharge meds: Metformin 500 t.i.d (refused insulin), losartan 50 mg o.d, atorvastatin 10 mg h.s, Aspirin
300 mg o.d
m
21/12/2021
• Signs of early Rt foot infection (fever, localised swelling, redness, and pain)
• Still non-compliant medicine & recommended lifestyle modification
ch
Plan:
• Abx treatment for foot infection, Tab. Cephalexin 500mg PO b.i.d, Tab. Paracetamol 1000mg P.O q4hr
for fever.
• Referral to endocrinologist for management of uncontrolled BG and related complications
en
Writing Task
Using the information in the case notes, you need to write a referral letter to the
endocrinologist. Address the letter to Mr. Jack Stevens, New Horizon Medical Centre,
ub
288 Herston Rd, QLD.

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WRITING SUB-TES: MEDICINE

Name: Julia Smith

• Burst water bag 6 hrs ago

• Ruptured amniotic membranes

Baby’s Nursing notes

WRITING SUB-TEST: MEDICINE

Presenting Complaints (started 24 hours ago):

Past Antenatal Visit:

Weekly visits advised

Past Medical History:

Past Surgical History:

Past Gynecological and Obstetric History:

Provisional Diagnosis: Pre-eclampsia

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WRITING SUB-TEST: MEDICINE

Date of Admission: 26/06/2021

Diagnosis: Traumatic head injury (RTA)

• Smokes 9 cigs daily

• DO NOT use note form in the letter.

• Use formal letter format.

WRITING SUB-TEST: MEDICINE

Past medical history:

Past surgical history:

• Laparoscopic varicocele repair (25th April 2017)

• 3 siblings, patient is youngest.

• 10-12 cigarettes per day for 15 years

• Captopril 12.5 mg PRN (BP >140/90)

Reason for referral:

• Treponema pallidum particle agglutination (TPPA) test: positive

Diagnosis: Secondary syphilis

• Tab. Doxycycline 100 mg BID for 14 days

• Report local health department

○ Inform and assess all possible contacts maintaining confidentiality

• DO NOT use note form in the letter.

WRITING SUB-TEST: MEDICINE

• Dish-face deformity, multiple lacerations

• Eye movements and vision normal

• DO NOT use note form in the letter.

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WRITING SUB-TEST: MEDICINE

Date of Admission: 14/11/21

Initial ED diagnosis: ? Myocardial infarction

• Diet - low salt, low fat, low carb

• DO NOT use note form in the letter.

WRITING SUB-TEST: MEDICINE

Reason for Admission: Decompensated Schizophrenia

• 1 half sister (maternal)

• Limited family support (lives with brother)

• Fortnightly IM inj. Clopixol depot 200 mg (next due on 09/01/2022)

○ re-emphasise treatment compliance

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