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Case Notes 3.1 Alfred Billy

Occupational English Test




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

  • Hospital Royal Perth Hospital
  • Today’s date: 11/05/2023

Patient Details

  • Alfred Billy
  • 52 Years old
  • Marital Status: Married (Maria Jennifer, lives separately but not divorced).
  • Address to contact wife: Sun City Arcade 207 Murray Street, Perth; (to be contacted if there is any serious emergency; She has dementia and difficulty travelling)


  • Admission Date 6/05/2023
  • Discharge Date 12/05/2023
  • Diagnosis: Basal Cell Carcinoma, neck
  • Nodular basal-cell carcinoma (?)

Past Medical History

  • No prior hospitalization;
  • No history of medication;


  • Truck Driver
  • Habit of consuming liquor for the past 30 years;
  • Cigarette Smoker;
  • Skin dark.
  • Religion: Protestant.
  • Address: Breeze Villa, opp. Davon House Complex, Silver Line, Birmingham – 35224

Medical Progress

  • BCC Removed
  • Mild Wound infection, breakdown, Suture reactions.
  • ? Incomplete excision.
  • Healing normal, no persistent swelling.
  • Pain reliever: Panadeine forte 500mg
  • Skin biopsy taken for further pathological study

Nursing Management

  • No complications noted
  • Perfectly well for discharge
  • No complaint of any pain

Discharge Plan

  • Daily observation
  • Medicine to be taken for one more week.

Writing Task

You are the charge nurse on the hospital ward where Mr. Alfred Billy has recently had his operation. Using the information provided in the case notes, write a referral letter to the Community Nurse Head at Care Well Hospital, Birmingham, who will be attending to Mr. Alfred Billy, following his discharge.

In your answer:

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

The body of the letter should be approximately 200 words.

What do you think?

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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