Case Notes 20.4 Toula Athena

OCCUPATIONAL ENGLISH TEST

TIME ALLOWED:

READING TIME: 5 MINUTES
WRITING TIME: 40 MINUTES

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

Notes:

• Patient: Mrs Toula Athena, 47, married, two children, home duties.

Family history

• Mother diabetes, died stroke 10 years ago aged 67

Medical history

• Unremarkable, no medications

Social History

• Married 2 children, home duties

11/07/2023

Subjective:

• 4 months thirst, bulimia, nocturia (4 times per night)
• lethargy 7 weeks
• dizziness

Objective:

• 1.60 Wt. 95 kgs.
• Pulse 84 reg, BP 160/95

Plan: Arrange investigations – blood sugar, midstream urine (MSU)

Dietary advice re weight loss, appropriate foods

15/08/2023

Subjective:

• Reports has followed diet, no weight loss
• Symptoms unchanged
• Frequent headaches

Objective: No weight loss; BP 170/95

Investigation results:

• Blood sugar 11 mmol / l
• No sugar in urine
• Albumin in urine + +

Plan:

• Prescribe antidiabetic and antihypertensive
• Medications, continue diet

05/09/2023

Subjective:

• Complains feeling worse
• Blurred vision
• Sight spots

Objective: BP 165/90

Plan: Referral Dr. Haldun Tristan, endocrinologist

Writing Task:

Using the information in the case notes, write a letter of referral to Dr Tristan, an endocrinologist at Melbourne Endocrinology Centre, 99 Brick Road, East Melbourne 3004.

In your answer:

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

The body of your letter should be approximately 200 words. Use correct letter format.