Day 4 Case Notes Analysis

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.


Mr David Hussein has been diagnosed positive for Covid19. You are nurse in charge, Abu Dhabi International Airport corona-virus screening section.

Patient details

  • Name Mr David Hussein
  • Age 56 years
  • Symptoms – coughing, sneezing, fever last four – five days, SOB with frequent headaches.

Social History

  • Resident, North Park, Rome, Italy.
  • Lives with wife, two children (youngest 7 years)
  • Evening chatting with friends. Often contacted with family members. BMI 34. Sedentary lifestyles
  • Retired police officer. National soccer player – 20 years ago
  • 20-25 cigarettes per day. Consumes alcohol 4 -5 units daily (under stress).
  • Receives pension for the aged / retired.

Medical History

  • Bronchial asthma, Diabetes mellitus type 2
  • Inhaler last one year
  • Hypertensive (2 years)
  • Lisinopril 10 mg everyday after meals
  • Left lung resection in 2016
  • Recurrent chest infections
  • Glipizide 40 mg and Metformin 500 mg twice daily
  • Hernia repair in 2006, Fracture (ankle) 2008, Allergic to penicillin
  • Mother died of Colon cancer, 2000, Father healthy, Rx BP and DLP under control


  • Screened two times
  • Temp 39°C ;
  • Pulse, 75 beats/ min

Travel History

  • Beijing – 10 January; Tianjin – 11 January; Weifang – 12 January; Nantong – 13 January; Taiwan – 14 January; Malaysia – 14 January
  • Frequent traveler to middle East (business purpose)
  • January 16 – Met Mr Dorman, at Al Souk, Abudhabi, at his residence and stayed with his family (including Mr Dorman’s 96 year old father and three adult sons)
  • Visited another friend’s (name and address not available) home yesterday (January 17).
  • Went to Al Wakra Public Park with Mr Dorman and spent around 2 hours. (More than 40 people were present in the park)
  • Disappeared from the observation ward and boarded flight to Milan (Italy) at 5.00 am this morning.


  • Encouraged proper personal protective equipment especially mask and gloves.
  • Advised to drink hot water
  • Tab pcm 500 mg 2 prn
  • Hydrated, 500 ml DNS
  • Nebulization every 4 hours (Mr Hussein has left the nebulizer behind)


  • Isolate Mr Hussein once he arrives in Milan
  • Wait for a second throat swab result (or PCR) and blood reports from your end.
  • (Mr Dorman and family have been contacted and instructions have been passed to their district authorities to send the entire family into quarantine for 14 days)

Writing Task

Write an emergency letter to the head nurse, Covid19 screening section, Milan International Airport, requesting to isolate Mr Hussein on his arrival at 8.20 and to admit him in the emergency department. You are nurse in charge, Abu Dhabi International Airport coronavirus screening section.

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:

  • Question of

    Single patient or multiple patients?

    • Single
    • Multiple
  • Question of

    Who is the primary patient?

    • A woman
    • A man
    • A baby
  • Question of

    What is the primary patient’s current condition?

    • Covid19 suspected
    • Bronchial asthma
    • Diagnosed with Covid19
  • Question of

    Who is the recipient?

    • Nurse
    • Doctor
    • relative
  • Question of

    What is the purpose of the letter?

    • Quarantine
    • Admission
    • Home visit
    • Advice / information
  • Question of

    Which information in the case notes is least relevant?

    • Travel history
    • Profession
    • Current Medication
    • Past medical history
  • Question of

    What’s tricky?

    • Confusion in plan
    • Nothing tricky
    • Confusion in purpose
  • Question of

    Admission / Discharge details:

    • Presently admitted
    • Presently discharged
    • None of the above
  • Question of

    Is the patient known / not known to the recipient?

    • Known to the recipient
    • Not known to the recipient
    • Uncertain about it
  • Question of

    Time of Writing (ToW)

    • Morning
    • Noon

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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  1. 18 January,2020

    The Head Nurse
    Covid-19 Screening Section
    Milan International Airport

    Dear Nurse,

    Re : Mr David Hussein,56 years

    I am writing to request an emergency admission for Mr Hussein who has been diagnosed with covid-19.He will be arriving at Milan International Airport at 08:20 am today.

    Yesterday, Mr Hussein presented to our covid-19 screening department with complaints of fever,cough,and sneezing following a recent overseas travel including China.On assessment,he was screened twice for the infection and complained of shortness of breath with frequent headaches.

    While in our care,Mr Hussein’s treatment commenced on intravenous fluids and antipyretics.In addition,he was initiated with nebulizations.He has been encouraged to wear personal protective equipment including masks and gloves. Today morning,he disappeared from the observation ward and boarded a flight to Milan,Italy at 05:00 am.

    Mr Hussein is an Italian resident and a frequent traveller.He consumes 4 to 5 units of alcohol and smokes 20-25 cigarettes daily.In terms of his past medical history,he is hypertensive and type 2 diabetic and is being managed with regular medications.He has bronchial asthma and uses an inhaler.It is worth mentioning that he had left lung resection in 2016.

    In view of the above information,it would be appreciated if you could provide isolation for Mr Hussein upon arrival in Milan Airport and further medical management as deemed as appropriate.

    If you have any queries, kindly contact me.

    Yours faithfully,
    Charge Nurse

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