Day 1 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:



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

Notes: Ms. Bethany Tailor is a 35-year-old patient in the psychiatric ward where you are working as a doctor. Hospital: St. Mary’s Public Hospital, 32 Fredrick Street, Proudhurst.

Patient Details:

  • Ms Bethany Tailor
  • Next of Kin: Henry Tailor (father, 65) and Barbara Tailor (mother, 58)
  • Admission date: 01 March 2018
  • Discharge date: 18 March 2018
  • Diagnosis: Schizophrenia

Past medical history:

  • Hypertension secondary to fibromuscular dysplasia
  • Primary hypothyroidism
  • Levothyroxine 88 mcg daily

Social background

  • Unemployed, on disability allowance for schizophrenia.
  • History of polysubstance abuse, mainly cocaine and alcohol.
  • Last used cocaine 28/02/18:



  • Patient self-admitted: decompensated schizophrenia
  • Medical background:
  • Not compliant with medications.
  • Admitted for auditory command hallucinations telling patient to harm self.
  • Visual hallucinations – shadow figures with grinning faces.
  • Delusion – personal connections to various political leaders.


  • Agitated and aggressive, responding to internal stimuli with thought blocking and latency.
  • Commenced antipsychotic meds (rispoderone).


  • Patient ceased reporting auditory or visual-hallucinations.
  • Less disorganised thinking.
  • No signs of thought blocking or latency.
  • Able to minimise delusions and focus on activities of daily living.

Nursing management:

  • Assess for objective signs of psychosis.
  • Redirect patient from delusions.
  • Ensure medical compliance.
  • Help maintain behavioral control, provide therapy if possible.


Good progress, chronic mental illness, can decompensate if not on medications or abusing substances. Insight good, judgment fair.

Discharge plan:

  • Discharge on Risperidone 4g nightly by mouth.
  • Risperidone 1 milligram available twice daily p.r.n for agitation or psychosis.
  • Back to apartment with follow-up at Proudhurst Mental Health Clinic

Writing Task

Using the information given in the case notes, write a discharge letter to the patient’s primary care physician, Dr. Giovanni DiCoccio, Proudhurst Family Practice, 231 Brightfield Avenue, Proudhurst

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:

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.

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Day 3 Case Notes Analysis

Day 2 Case Notes & Analysis (Med)