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Case Notes 2.2 Jake Peterson

Occupational English Test

Writing: Nursing

Reading Time: 5 Minutes. Should not write during this time.
Writing Time: 40 Minutes

Notes:

You are a nurse at a boarding school. Jake Peterson is a male student at your school and has come to you complaining of hair loss and associated depression.

Patient Details:

  • Name: Jake Peterson
  • DOB: 17.03.2005 (18 years)
  • Address: Holly House School, Bembridge.

Social Background:

  • Student at boarding school for past 8 years.
  • Parents work & live abroad
  • Father (male-pattern baldness-onset in 50s)
  • Mother (depression-onset in 40s)
  • Non-smoker, 20 units alcohol/week
  • Karate black belt champion; swimmer

Presenting Complaint:

  • Alopecia-hair loss from 13 years of age.
  • Intermittent cycles (loss and regrowth).
  • Etiology not confirmed (various possibilities. ?Depression)

Treatment Summary

April 2018

  • School clinic – presented with hair loss in patches; anxiety
  • Onset: School bullying incident.
  • Pt said ‘not a major thing.
  • Referral to trichology specialist.

June 2018

  • Trichologist: No etiology established, possibly exacerbated by stress.
  • Prescribed steroid cream (betamethasone dipropionate 0.05% cream 1-2x/day for 3 moths)
  • Personality changes, aggression, sleep loss.
  • Medication discontinued.

2018 – 2022

  • No further hair loss; intermittent hair regrowth.

January 2023

  • Return of anxiety and pronounced hair loss.
  • General health check ↑6 kg over last 2 months.
  • Recommended Dr consultation Re hair loss, anxiety, weight loss.
  • Jake reluctant. Sought natural remedies (homeopathy)
  • Efficacy suspected yet Jake keen to try.

March 2023

  • Reports no results + cost implications of homeopathic treatment (kalium carbonicum and silicea) → Jake distressed, low mood.
  • Problems forming/maintaining peer relationships.
  • Affecting sports participation.

April 2023

  • Referred to school counsellor. Did not attend

June 2023

  • Check-up: + alcohol consumption, min 28 units/wk

2019 July – August, 2023

  • Exam time-extreme anxiety (necessary to arrange separate exam room)
  • Hair loss.

19 September 2023

  • Jake concerned about transition to university shortly and independent living.
  • Letter to university medical practice. Monitor. Organise special exam arrangements.

Writing Task

Using the information given in the case notes, write a letter to Mrs Monica Hendrik, a university practice nurse. In your letter, briefly outline Jake Peterson’s history and your concerns. Address your letter to Mrs Hendrik, Senior Nurse Practitioner, University of March Bank Health Centre, Hills Dune Rd, March Bank.

In your answer:

  • Expand the relevant notes into complete sentences.
  • Do not use note form.
  • Use letter format.

Your letter should have a word count of 180 – 200 hundred words. However, the numbers can go up or down depending on the relevance of information.

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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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