Day 19 Case Notes Analysis



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


Nicholas Brihman, 61-year-old man, presents to his primary care provider Dr Maria Jones, complaining of recent, recurrent episodes of angioedema. You are a charge nurse at this facility.

Patient Details

  • Mr Nicholas Brihman, 61
  • Traveler and blogger, not married, next of kin – brother
  • Lifestyle: Sedentary, sleeps less, active
  • The patient lives in the Southeast and when questioned about tick exposure, he confirms having removed a tick about a year previously, after a long day spent outdoors.


  • Meat-heavy meals (including steak and barbecued pork).
  • Eats heavy meals at night.
  • Occasionally alcoholic, cigar smoking
  • Up to date on all immunizations.

Medical History

  • High blood pressure (since 2001)
  • On medication – Lisinopril, perindopril and ramipril, ibuprofen
  • Negative for rashes, changes in skin color, sores or new lesions, and headaches.
  • A history of persistent mild childhood asthma and intermittent adult asthma.


  • Emergency department for facial swelling.
  • Diagnosed as angioedema (related to stress and eating spicy foods).
  • Advised to eliminate spicy foods and other triggers.
  • Prescribed epinephrine auto-injector, diphenhydramine 50 mg.


  • Revisits with complaints of 4 episodes of severe angioedema over an 8-month period.
  • Reported irritation of the left eye, sinus pressure, numbness and tingling in the mouth, and swelling of the lips, throat, and tongue (3 to 4 hours after he eats a large meal)
  • Expresses concern that his symptoms will progress to anaphylaxis.
  • Important! Has not needed the epinephrine auto-injector.
  • Complains of constricted airway during his reactions.
  • Denies shortness of breath, coughing, and wheezing.


  • Tested positive for seasonal allergies (grasses, trees, and cat dander) but has no history of food or drug allergies.
  • Bilateral swelling in the lips, cheeks, and soft tissue under the jaw.
  • The left side of face more severely swollen than right.
  • Difficulty closing mouth (due to swelling).
  • Mild periorbital swelling, and the sclera of both eyes are mildly pink and watery.
  • No chemosis present, no noticeable skin change, redness, or urticaria on the face, trunk, or limbs.
  • IgE skin prick test (SPT) ordered to rule out new allergies to protein in his diet.


  • SPT is performed for commercial extracts of beef, pork, lamb, chicken, turkey, and milk, as well as cat and dog dander.
  • The patient tests positive for hypersensitivity reaction to cat dander, revealing a 3 – to 5 mm wheal with flare.
  • All other SPT results negative.
  • These results, along with the patient’s history of tick bite and angioedema after high-protein meals, confirm a diagnosis of red meat allergy, or α-gal syndrome.
  • Blood samples collected for immunoassay to detect IgE to galactose-α-1, 3-galactose (α-gal).
  • The patient tests positive for IgE antibodies to α-gal with the serum assay.

Writing Task

As Dr Jones is under house quarantine for Covid19 from today, 22nd June, 2020, Mr Brihman needs to be referred to Dr Mathias Brown, Royal Lake Hospital, Yamba Dr, Garran ACT 2605, Canberra, Australia +61351240000. As charge nurse, write this letter detailing Mr Brihman’s concerns.

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

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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