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Case Notes 4.4 Martin Wilson

Occupational English Test



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


The patient was admitted after an attempt to suicide and is coming back to a notably normal state.

  • Today’s Date: 19 September, 2023
  • Hospital: Lyell McEwin Hospital

Patient Details:

  • Name: Martin Wilson
  • Age: 62
  • Admission Date: 09 September, 2023
  • Discharge Date: 20 September, 2023
  • Diagnosis: Attempted suicide — overdose of Mogodol.

Past Medical History:

  • Heavy smoker (40 cigarettes/day).
  • Bronchitis (multiple episodes).
  • Underweight – 66 kg, BMI 18.

Social History:

  • Retired 2 years ago (book-keeper with Holden Car)
  • Lives with wife, Joan, and adult son in Housing Trust, Elizabeth.
  • Wife works at Coles, son unemployed.
  • 2 married daughters and 5 grandchildren.
  • Regular social drinker.
  • Used to be a keen lawn bowl player.

Gambling History:

  • Depression related to gambling addiction
  • Began gambling 2 years ago
  • Has lost a lot of money including superannuation for debt.
  • Wife and family previously unaware of addiction also upset about suicide attempt
  • Patient remorseful and ashamed;
  • Wants to overcome addiction.
  • Has lost friends as result of gambling.

Nursing Management:

  • Weak and depressed.
  • Anti-depressants prescribed – Lovan 200 gm.
  • BP 130/95
  • Diagnosed with Type II diabetes.
  • Diabetes education regarding diet and oral medications;
  • Wheelchair use from 20/10
  • Psoriasis on Torso and scalp – Diprosone OV cream 2x/day, Ionil T Shampoo.
  • Poor appetite
  • Physically unfit.

Discharge Plan:

  • Encouragement to maintain anti-depressant medication routine as the SSRI is established.
  • Mrs Wilson will help with supervision.
  • Monthly follow-up appointments with psychologist Dr Brian Murphy, Lyall McEwen Hospital.
  • Social worker appointment to be made for gambling addiction therapy.
  • Strong encouragement and assistance to join Gambling Addiction Action Group, Elizabeth Community Centre.
  • Contact with Quitline needs to be encouraged.
  • Wheel chair required for another week.
  • Frame advised after this
  • Maintain psoriasis treatment
  • Maintenance of low GI diet for diabetes –
  • Involvement of wife necessary.
  • Encouragement in social sporting activities (eg: lawn bowls?)


Using the information in the notes, write a letter to the social worker, Ms Jennifer Adams, at the Elizabeth Community Health Centre, 125 Munno Parra Avenue, Elizabeth, 5098 requesting follow-up care. Stress that Mr Wilson’s case needs urgent attention.

In your answer

  • Expand the relevant case 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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