Day 2 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:



Patient Details

  • Hospital: Fairbanks Hospital, 1001 Noble St, Fairbanks, AK 99701
  • Name: Mrs Sally Fletcher
  • Date of Birth: 3/10/1993
  • Marital status: Married, 5 years
  • Appointment date: 25/03/2018
  • Diagnosis: Endometriosis

Past medical history

  • Painful periods 3 years
  • Wants children, trying 1 year ++

Social background

  • Accountant, regular western diet.
  • Exercises 3 x week local gym

Medical background:

  • Frequent acute menstrual pain localised to the lower left quadrant.
  • Pain persists despite taking OTC = naproxen.
  • Shy discussing sexual history.
  • Occasional constipation, associated with pain in lower left quadrant.
  • Trans-vaginal ultrasound showing 6 cm cyst, likely of endometrial origin.
  • Patient recovering post op from laparoscopic surgery (25/03/2018) – no complications
  • Post op care: Keep incisions clean and dry.
  • Mobility post op – Showering is permitted
  • 26/03/2018
  • Driving is prohibited when on analgesics.
  • Driving can be resumed 24-48 hrs after final dose analgesics.

Sexual activity can be resumed 2 weeks post op.

Nursing management:

  • Encourage oral fluids.
  • Patient may return to regular diet.
  • Ambulation encouraged as per patient tolerance.

Medical progress

  • Afebrile. Hct, Hgb, Plts, WBC, BUN, Cr, Na, K, Cl, HCO3, Glu all within normal limits.
  • Patient sitting comfortably, alert, oriented × 4 (person, place, time, situation).
  • Assessment:  Good progress overall.

Discharge plan:

  • Patient to be discharged when can eat, ambulate, urinate independently.
  • Patient must be discharged to someone who can drive them home.

Writing Task

You are a first year resident in a surgical ward. Sally Fletcher is a 25-year-old woman who has recently undergone surgery. You are now discharging her from hospital.

Using the information given to you in the case notes, write a letter of discharge to the patient’s GP, Dr Stevens, Mill Street Surgery, Farnham,GU10 1HA.

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 1 Case Notes & Analysis (Med)

Day 3 Case Notes & Analysis (Med)