Task 3 Case Notes: Dulcie Wood

Read the cases notes below and complete the writing task which
follows:

Time allowed: 40 minutes

Today's Date

08.08.09

Patient History
Dulcie Wood

DOB 15.07.43

New patient in your General Practice. Moved recently to be near

family.

03.07. 09
Subjective
Widowed January 06, three children, wants regular check up, has
noticed uncomfortable feeling in her chest several times in the last
few weeks like a heart flutter.
Mother died at 52 of acute myocardial infarction, non smoker, rarely
drinks alcohol
Current medication: zocor 20mg daily, calcium caltrate 1 daily
No known allegeries

Objective
BP 145/75 P 80 regular
Ht 160cm Wt 61kg
Cardiovascular and respiratory examination normal ECG normal

Plan
Prescribe Noten 50 gm ½ tablet daily in am. Advise to keep record
of frequency of fibrillation sensation.
Review in 2 weeks if no increase in frequency.

17.07.09
Subjective
Reports sensations less but woke up twice at night during last 2
weeks

Objective
BP 135/75 P70 regular
Assessment
Increase Noten to 50 gm daily ½ tablet am and ½ tablet pm
Advise review in one month.

08.08.09
Subjective
Initial improvement but in last 3 days heart seems to be fluttery
several times a day and also at night. Very nervous and
upset. Wants a referral to a cardiologist Dr.Vincent Raymond who
treated her sister for same condition

Objective
BP 180/90 P70

Action
Contact Dr Raymond’s receptionist and you are able to arrange an
appointment for Mrs Wood at 8am on 14/08/09

Writing Task

Write a letter addressed to Dr. Vincent Raymond, 422 Wickham Tce,

Brisbane 4001 describing the situation.

In your answer:

 Expand the relevant case notes into complete sentences

 Do not use note form
 The body of the letter should not be more than 200 words
 Use correct letter format