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Case Notes 4.1 Joan Romana

Woman doctor wearing lab coat with stethoscope isolated

Read the case notes and mark the following elements on your notebook:

  1. Patient’s Name, Age, Address
  2. Purpose of writing this letter.
  3. Recipient’s Name, Designation, Address.
  4. Requests (Discharge Plan)
  5. Admission / Presenting / Visiting Condition.
  6. Admission / Presenting / Visiting Date.
  7. Discharging / Transferring Condition.
  8. Discharging / Transferring Date.
  9. Date of Writing.
  10. Diagnosis Status (Diagnosed / Not Diagnosed)
  11. Direction (ABA, ABC, ABB, BA)
  12. Writer (Nurse?)
  13. Known Case / Semi Known case / Unknown Case)

Occupational English Test




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


You are Nurse working at Basil’s Mother and Child Hospital, London. You have noticed that Ms Romana, who has delivered her first baby in your hospital, has postpartum psychosis.

Today’s Date: 02/10/2023

Patient Details

  • Name: Joan Romana
  • Age: 24

Baby Birth History

  • DOB: 12/09/2023
  • Normal Birth.
  • All vitals normal.
  • Discharged on 15/09/2023

Past Medical History

  • Developed signs of bipolar disorder (2019, September).
  • Consulted a psychiatrist at Blue Moon Mental Health Clinic, Museum Road, London (North) in 2029, October.
  • Patient failed to follow up.
  • Under medication for a year. Stopped (excessive weight gain, sleepiness).


  • When visited by a community health worker Ms Pink Clemence, Ms Romana was said to be overly happy on the five days following the birth of the baby.


  • Follow up visit
  • Appeared anxious
  • Said, “I was expecting a girl.”
  • Said she would settle back in Germany, with her parents.
  • Mildly obsessive about filing her nails, talks non-stop.
  • Hesitant to breastfeed the baby.
  • Absent minded.

Today (Based on Ms Clemence’ Observations received over phone):

  • Slept till 11.30 am
  • Complained loss of appetite.
  • Ignores the baby.
  • Husband visited at 11.45.
  • Postpartum Psychosis (?)


  • Needs assessment.

Writing Task

Write a referral letter to Dr Stephano Milton, Perinatal Psychiatrist, at Blue Moon Mental Health Clinic, Museum Road, London (North).

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.

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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