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

notes:

Today's Date 03.07.12

Patient History

Margaret Leon 01 .08. 52

Gender: Female

Regular patient in your General Practice .

14.01.12

Subjective

Wants general check up, single, lives with and takes care of elderly mother.

Father died bowel cancer aged 50.

Had colonoscopy 3 years ago. Clear

Does not smoke or drink

Objective

BP 160/90 PR 70 regular

Ht 152cm

Wt 69 kg

On no medication

No known allergies

Assessment

Overweight. Advised on exercise & weight reduction.

Borderline hypertension

Review in 3 months

25.04.12

Subjective

Feeling better in part due to weight loss

Objective

BP 140/85

PR 70 regular

Ht 152cm

Wt 61 kg
Assessment

Making good progress with weight. Blood pressure within normal range

03.07.12

Subjective

Saw blood in the toilet bowl on two occasions after bowel motions. Depressed and very anxious.

Believes she has bowel cancer. Trouble sleeping.

Objective

BP 180/95 P 88 regular

Ht 152cm Wt 50 kg

Cardiovascular and respiratory examination normal.

Rectal examination shows no obvious abnormalities.

Assessment

Need to investigate for bowel cancer

Refer to gastroenterologist for assessment /colonoscopy.

Prescribe 15 gram Alepam 1 tablet before bed.

Advise patient this is temporary measure to ease current anxiety/sleeplessness.

Review after BP appointment with gastroenterologist

Writing Task:

Write a letter addressed to Dr. William Carlson, 1st Floor, Ballow Chambers, 56 Wickham Terrace,

Brisbane, 4001 requesting his opinion.

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.