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Case Notes 3.4 Tom Clarke

Case Notes 3.4 Tom Clarke



Reading: 5 Minutes + Writing 40

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


You are Ramona Decosta, a senior nurse working with Helpline Hospital.

  • Patient name: Tom Clarke
  • DOB: 21/09/1955
  • Address: 92 Lygon Street, Carlton, Melbourne
  • Phone: 0422-894-896.

Social Background:

  • Married Wife – “Miranda” Clarke, aged 58 years. Live together.
  • Retired – Army officer.
  • Two daughters – elder daughter works in Sydney, younger daughter – Adelaide.
  • Quite active.
  • Hobbies: Cycling, watching movies, sports, reading, travelling, playing golf and Tennis.

Surgical History:

  • R Ankle dislocation surgery following a car accident, 1989.
  • Hospitalized for 3 weeks.
  • Septoplasty – 1991.
  • Surgery for Anal Fistula – 1999
  • Eye replacement lens surgery – 2014.

Medical History:

  • Hypertension – 1992 (Did not seek treatment till 2007; now managed with Ramipril)
  • GERD – 2006.


  • Accident with a motorbike while cycling, claimed he was going at a moderate speed, a motorbike hit him while overtaking, landed on the left side of his body.
  • FOOSH (Fall on outstretched hand) injury to L elbow, presented to ER, limited range of motion and extreme pain.
  • X-RAY – Nondisplaced fracture of the coronoid process of the ulna, marrow oedema head and neck of radius involving articular surface, moderate joint effusion.


  • Sling to keep the elbow immobilized- 6 weeks,
  • Capsule CM Plus, Panadol, Ibuprofen, hot compress for pain and inflammation
  • Next Appointment in 6 weeks’ time.


  • X-ray – injury healing well
  • Tab DGain qw
  • Tab CM Plus – qd
  • Sling taken off
  • Exercise program – at home.

29/04/2023 (today)

  • Complains of stiffness and limited range of motion in the elbow
  • Arrange home visits by physiotherapist for rehab program.
  • Tab DGain qw
  • Tab CM plus qd
  • Follow-up appointment – 20/05/2023.

Writing task

Write a referral letter to Amit Kumar, Physiotherapist, Suite 5, 379 Swanston Street, Melbourne requesting home visits for the patient.

In your answer:

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

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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