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Case Notes 10.1

10.1 Mrs Boris Johnson




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


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.


  • 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


  • 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


  • 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.

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Written by English Melon

Biju John, author of ByeBle and Maclins, is an English Language Trainer. He has also authored his educational Fiction. All these titles are available on Amazon and Google. You can contact his office on WhatsApp / Telegram number +917510923061

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