Day 9 Case Notes Analysis

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:



Read the case notes below and complete the writing task which follows.


You are a Registered Nurse at the Queensland City Hospital were Rosario Lebanon is a patient in your care.

Today’s date: 29/05/2017
Patient name: Mr Rosario Lebanon
Address: Unit 12, 65 White Street, Brisbane 4800
Age / DOB: 19/07/1931
Next of Kin: Son, Jewel Lebanon, 52 years old, unmarried – lives 30 minutes away

Medical History

Dx Klinefelter’s syndrome (when he was 17 years)
Orchiectomy (when he was 19 years; Right testicle removed)
Dx Breast Cancer 20 years ago, right total mastectomy (same year).
Did not receive adjuvant radiation, chemotherapy, or hormone therapy or medical follow-up post-operatively.

Diagnosis: Recurrent infiltrating ductal carcinoma of the breast.

Other conditions / details: Dementia, Non-smoker, No known allergies, Non-drinker

Family History

Mother died of colon cancer (68 years)

Social History

Retired 20 years ago as fabrication manager,
Married – Wife (Evania M Lebanon) suffering from newly onset dementia


Presented to ER with ulcerated, hemorrhaging right anterior chest mass
Developed a mass on his anterior chest wall – 2 years ago
Mass increased in size, began to ulcerate – bled this morning — did not seek medical treatment until this morning


  • Temperature – 97.4°F
  • Pulse- 80 RR – 14
  • Pulse oximetry of 100% on room air
  • BP – 162/88.

A right-sided pedunculated 8 cm × 7 cm mass with a cauliflower-like appearance on chest – ulcerated, erythematous, malodorous, and with scant bleeding.

  • White blood cell count 6,500
  • Haemoglobin 12.4
  • Haematocrit 36.2
  • Platelet count 178,000.
  • Creatinine of 1.72 Glucose 106

A CT chest – a soft tissue mass in right chest wall measuring 5.2 × 2.75 × 5 cm with postoperative changes of the right axilla. Incisional biopsy of right breast mass performed.


Pathology returned consistent with recurrent moderately differentiated duct carcinoma of the breast with ulceration of overlying epithelium (Stage 3).
Pt. not found to be suitable for chemotherapy or curative treatment
Oncology evaluation and geriatric evaluations by doctor.
Pt. commenced on hormone therapy with tamoxifen 20 mg daily with one course of palliative radiation.
Family meeting called. Son verbalized concerns over mother’s state of health;
(Son unable to take time off work to care for father – Says he won’t be able to cope)

Hospice care recommended for pt (Consensus decision)
Pt. to be transferred to Queensland Aged Care Centre for hospice care.
Bed available from 29/05/2017 for patient.

Mrs Lebanon to be admitted to the same facility due to general deconditioning when bed is available; Now to live with son interim.

Discharge plan

  • Transfer to Aged Care home
  • Son will visit weekly
  • Contact community social worker to notify son when bed available for wife at Queensland Aged Care Center.

Writing Task

Using the information in the case notes, write a referral letter to the Ms Perry Smith, Director of Nursing, Queensland Aged Care Center, 80 Ferdinand Magellan Block, Brisbane 4191, introducing the patient. Using relevant case notes, give his background, medical history, and treatment required.

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 take this Case Notes Analysis and proceed to Letter Writing 

  • Question of

    Adjuvant radiation is a therapy:

    • Preoperatively
    • Postoperatively
  • Question of

    What is the purpose of this letter?

    • Home Care
    • Treatment
    • Aged Home Admission
  • Question of

    Who is the recipient of this letter?

    • Nurse in charge of home visit
    • Nurse at aged care home
    • Nurse at a hospital
  • Question of

    How many patients are being referred in this case notes?

    • Single patient
    • Two patients
  • Question of

    For whom is this letter is written?

    • Primary patient
    • Both patients
  • Question of

    Why is the patient not getting any chemotherapy or curative treatment?

    • The patient is not suitable
    • The patient has refused to
    • The patient’s relatives have disagreed
  • Question of

    What is the admission / discharge status?

    • Already discharged
    • Being discharged today
    • Will be discharged tomorrow
    • Not scheduled

Leave a Reply

Your email address will not be published. Required fields are marked *

GIPHY App Key not set. Please check settings


  1. 10 June,2020

    Ms Petra Cornwallis
    Registered Nurse
    Community Health Center

    Dear Ms Cornwallis,

    Re : Ms Kelly Skotch,21 years

    I am writing to introduce Ms Skotch,a 6-week-pregnant young lady, who requires your ongoing psychiatric support throughout her pregnancy.She has been facing substance abuse related issues and is being discharged today.

    Two days ago,Ms Skotch presented to our center due to concerns about her pregnancy.She also complained about her existing depressive symptoms.On assessment ,her pregnancy was confirmed and was screened for HIV and STDs.While in our care,she has been counselled regarding proper nutrition during pregnancy and the risks of sexually transmitted diseases.

    Ms Skotch has a history of chronic substance abuse including cannabis,cocaine and heroin and occasionally shares injecting equipment with multiple persons.She also consumes15 units of alcohol and smokes 30-40 cigarettes per day.Currently,she lives with her partner Ms Bleanly,who is also an opium addict and allegedly maintaining sexual relationship with her.She has suicidal thoughts and self-harming tendency.Although she is interested to quit her alcohol consumption and drug use,she still wishes to continue smoking.Please note,she has lost 6kg over the past two months.

    In view of the above ,kindly take over the care of Ms Skotch and provide daily mental health nursing services at least for the next two weeks.Please make sure her active participation in Methadone program and Alcoholic Anonymous meetings.Finally,she needs maternal health clinic appointments along with regular ultrasound monitoring every 2 weeks.

    Please contact me for any queries.

    Yours sincerely,

    Registered Nurse

  2. 29 May,2017

    Ms Perry Smith
    Director Of Nursing
    Queensland Aged Care Center
    80 Ferdinand Magellan Block
    Brisbane 4191

    Dear Ms Smith,

    Re : Mr Rosario Lebanon,85 years

    I am writing to refer Mr Lebanon who requires hospice care.He has been diagnosed with recurrent infiltrating ductal carcinoma of the breast and will be transferred today.

    Mr Lebanon presented to our hospital on 23 May,2017 with ulcerated, hemorrhaging right anterior chest mass. An incisional biopsy of the right breast mass was performed which confirmed the above mentioned diagnosis. As per the geriatric and oncology evaluation, he was found to be not suitable for chemotherapy or curative treatment.

    Mr Lebanon lives with his wife Mrs Evania M Lebanon,who is a newly diagnosed dementia sufferer. Their next of kin is their son who lives nearby.Their son expressed concerns over the care of his parents at home due to the nature of his work. As a result, a decision was made consensually to transfer them into your facility for further care. Please note, Mrs Lebanon will stay with his son until the availability of bed at your facility.

    In terms of Mr Lebanon’s past medical history, he had a total right mastectomy 20 years ago and failed to receive adjuvant chemotherapy and other medical follow-ups postoperatively.

    In view of the above, kindly take over the care of this elderly couple and provide necessary management. Please contact community social worker to notify their son when the bed is available for Mrs Lebanon.

    Yours sincerely,

    Registered Nurse

  3. Ms Perry Smith
    Director of Nursing
    Queensland Aged Care Center
    80 Ferdinand Magellan Block
    Brisbane 4191

    29 May,2017

    Dear Ms Smith,

    Re:Mr Rosario Lebanon,86 years

    I am writing to introduce Mr Lebanon who has been under our care for the treatment of recurrent infiltrating ductal carcinoma of the breast.He requires hospice care from your centre following his transfer today.

    Mr Lebanon presented to ER six days ago with a bleeding mass on the right anterior chest,which was developed two years ago and was not treated.Subsequently,he underwent routine investigations including incisional biopsy.His pathology reports confirmed stage 3 recurrent duct carcinoma of the breast with ulceration.Thereafter,he was started hormone therapy as he is not suitable for chemotherapy or curative treatment.

    Mr Lebanon has undergone right total mastectomy 20 years ago and did not receive any post operative follow up treatments.He and his wife has dementia.

    During family meeting which was held yesterday Mr Lebanon’s son has decided to transfer his father to your old age centre as he cannot cope up with this situation due to work.Mrs Lebanon also be admitted to your centre when bed is available.

    A community social worker has been contacted to inform son regarding bed availability for Mrs Lebanon.Son will visit the centre every weekly.

    Please contact me for further details.

    Yours sincerely,

    Registered Nurse
    Queensland City Hospital

  4. 29 May 2017

    Ms Perry Smith
    Director of Nursing
    Queensland Aged Care Center
    80 Ferdinand Magellan Block
    Brisbande 4191

    Re: Mr Rosario Lebanon, DOB: 19 July 1931

    Dear Ms Smith

    I am writing regarding Mr Lebanon, who has been diagnosed with breast cancer at terminal stage. He is being discharged and now, requires hospice care at your care facility.

    On 23 May, Mr Lebanon presented with an ulcerated, hemorrhaging mass on his anterior chest wall,for which he underwent incisional biopsy. His pathology reports revealed that he had recurrent moderately differentiated duct carcinoma. As per the treatment plan, he was found to be not suitable for chemotherapy. Therefore, he has been commenced on hormonal therapy with tamaxifen 20mg daily.

    Mr Lebanon lives with his wife, who has had dementia. He has a son who lives 30 minuts away. In terms of his medical background, he has had kilnefelter’s syndrome since age of 17. he underwent orchiectomy and right total mastectomy. Please be aware that his son is not able to take care of him as he is taking care of his mother.

    In view of the above, it would be greatly appreciated if you could welcome Mr Lebanon into your care. Please be aware that his son will visit him on a weekly basis.Please arrange a social worker to notify his son about bed vacancy for Ms Lebanon.

    If you have any question, please do not hesitate to contact me

    Yours Sincerely

    Registered Nurse

Written by Biju John

Love for English begins with understanding its unknown rules. Biju John lives on the internet, teaching OET, IELTS and PTE. More than a million students have thanked him from their heart.

Day 8 Case Notes Analysis

Day 7 Paragraph Labeling