Day 3 Case Notes & Analysis (Med)

This case notes will be used for writing today’s letters for correction. Before you proceed to writing this letter on the writing page, please read this case notes and answer the questions that below:



Office: First Family Primary Care, 3959 Abalone Lane, Omaha

Patient Details

  • Name: Tabitha Taborlin (Ms).
  • Marital status: Single. Next of kin: Gregory Taborlin (69, father).
  • Date seen: 08 April, 2018
  • Diagnosis: Type 1 diabetes mellitus
  • Past medical history:

Essential hypertension

  • Type 1 diabetes mellitus (non-compliant with insulin regimen)
  • Multiple episodes of diabetic ketoacidosis (DKA)

Social background:

  • School teacher, lives alone in apartment.
  • Does not exercise, BMI 18.2 (underweight – 48kg)
  • Smokes moderately (2 cigs daily)

Medical background:

  • Long history of Type 1 diabetes (since 7 y.o.) and noncompliance with insulin regimen.
  • On 45 units Lantus nightly and preprandial correctional scale Humalog with 12 unit nutritional baseline.
  • 02/04/2018: admitted DKA (glucose 530 mmo/L) IV fluids and insulin administered.
  • Discharge stable – HbA1c.
  • Appointment today:
  • Doing well since discharge.
  • Still not using insulin.
  • Has insulin available.
  • Not following recommended diet.
  • Discussed diabetes education, necessity of glucose testing, insulin administration, smoking
  • Cessation education.
  • Discussed microvascular/macrovascular complications of diabetes.


  • Discharge today – provide educational pamphlets and refills for Lantus and Humalog.
  • Referral to endocrine specialist for stricter glycemic control and possible insulin pump.
  • Follow-up in 1 month

Writing Task

You are a physician OR at a family medical practice. Ms Tabitha Taborlin is a 45-yearold patient at your practice.

Using the information given in the case notes, write a referral letter to Dr. Sharon Farquad, Endocrinologist at Endocrine Specialists and Associates, 115 Burke St. Omaha.

In your answer:

  • Expand the relevant notes into complete sentences
  • Do not use note form
  • Use letter format
  • The body of the letter should be approximately 180–200 words.

Now, proceed to the questions below and see your score:

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