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Day 4 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:

OCCUPATIONAL ENGLISH TEST

WRITING SUB-TEST: MEDICINE
TIME ALLOWED: READING TIME: 5 MINUTES
WRITING TIME: 40 MINUTES.

Notes

Today’s Date 07/11/10

Patient History

  • Mr David Taylor, 38 years old, married, 3 children
  • Landscape Gardener
  • Runs own business.
  • No personal injury insurance
  • Active, enjoys sports
  • Drinks 1-2 beers a day. More on weekends. Smokes 20-30 cigarettes/day
  • P.M.H-Left Inguinal Hernia Operation 2008
  • 12/08/10

Subjective

  • C/o left knee joint pain and swelling, difficulty in strengthening the leg.
  • Has history of twisting L/K joint 6 months ago in a game of tennis.
  • At that time the joint was painful and swollen and responded to pain killers.
  • Finds injury is inhibiting his ability to work productively. Worried as needs regular income to support family and home repayments.

Objective

  • Has limp, slightly swollen L/K joint, tender spot on medial aspect of the joint and no effusion.
  • Temperature- normal BP 120/80 Pulse rate -78/min
  • Investigation – X ray knee joint
  • Management: Voltarin 50 mg bid for 1/52 Advise to reduce smoking Review if no improvement.

25/8/10

Subjective

  • Had experienced intermittent attacks of pain and swelling of the L/K joint
  • No fever
  • Unable to complete all aspects of his work and as a result income reduced
  • Reduced smoking 15/day

Objective

  • Swelling + No effusion Tender on the inner-aspect of the L/K joint Flexion, extension – normal
  • Impaired range of power – passive & active
  • Diagnosis? – Injury of medial cartilage Investigation – ordered MRI
  • Management – Voltarin 50mg bid for 1 week
  • Review after 1 week with investigations

07/11/10

Subjective

Limp still present Patient anxious as has been unable to maintain full time work. Desperate to resolve the problem Weight increase of 5kg

Objective

Pain decreased, swelling – no change No new complications MRI report – damaged medial cartilage

Management Plan

Refer to an orthopaedic surgeon, Dr James Brown to remove damaged cartilage in order to prevent future osteoporosis. You have contacted Dr Brown’s receptionist and you have arranged an appointment for Mr Taylor at 8 am on 21/11/10.

Writing Task

You are the GP, Dr Peter Perfect. Write a referral letter to Orthopaedic Surgeon, Dr. James Brown: 1238 Gympie Road, Chermside, 4352.

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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