Case Notes 10.1

10.1 Mrs Boris Johnson

OCCUPATIONAL ENGLISH TEST

WRITING SUB-TEST: Nursing

READING TIME: 5 MINUTES | WRITING TIME: 40 MINUTES

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

NOTES:

You are Jake Venter, a qualified nursing sister, working under HiMMS Health Clinic. Boris Johnson is visiting your clinic.

Today’s date: 10 July, 2023

Patient Details

• Name: Mrs Boris Johnson
• Age: 44 years
• Address: Walsgrave, Bilham, CV 35 LB
• Phone: (0) 7657897345

Medical history:

• PCOS
• Endometrial hyperplasia;
• Excessive irregular growth
• Irregular menstruation since April 2023.
• Splenectomy in 2005.
• Cholecystectomy in 2021.
• Hyperthyroidism; on thyroxine 0.5 mg
• Allergy: nuts.

Family history:

• Mother died with uterine cancer.
• Father has diabetes.

08/07/2023

• Came into the clinic with severe vaginal bleeding
• Weight loss, pain while urination
• Pain during intercourse
• Pain in legs and back
• Pelvic pain
• Anorexia, tiredness
• Unable to do daily activities

Medical Background

• TFT (Thyroid Function Test)
• TVS (Transvaginal Ultrasound) – to find presence of polyp
• Complete blood test
• Hysteroscopy
• Panadol BD
• Recommend for review with lab reports

09/07/2023

• Unusual vaginal bleeding with foul smelling, pus-like or blood-tinged.
• Constipation, bleeding from bladder and rectum
• Ascites, lymph edema.
• Advised for PAP test and biopsy
• WBC increased and HB fell
• Electrolyte imbalance

10/07/2023

• Fainted at home, returned to clinic accompanied by her son
• Profound vaginal bleeding, intense pain 9/10, breathing difficulty
• Pap test showed abnormal growth of cells
• Blood in stools, UTI
• BP – 90/69 mmHg, weak and thready pulse, RR- 34
• Biopsy, MRI, CT, X-ray reports pending.

Discharge Plan:

• ? endometrial cancer
• Biopsy, MRI, X-ray report pending.
• Requires further assessment and treatment.

Writing Task

Using the information in the case notes, write a letter to Dr Morris Black, Oncologist at Lincoln Hospital, Butterfly Road, Liverpool, 6675, UK, to request further evaluation and its management.

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.