Task 2 Case Notes: Sally Webster

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

Time Allowed

Reading Time: 5 minutes

Writing Time: 40 minutes

Today’s Date
21/02/18

Patient Details

• Sally Webster
• DOB 10/11/01
• High school student

27/12/17
Subjective

• 3/12 constipation
• 1 firm bowel action every 4 to 5 days
• Diet includes 2 tablespoons of bran each morning
• Has tried laxatives
• Otherwise well

Objective

• Wt. 54kg
• BP 100/50
• P 70 reg
• Abdo: lax, no masses
• P.R. exam unremarkable
• Advised to increase vegetable, fibers and fluid intake.

15/02/18
Subjective

• Presents with mother. Mother concerned about Sally’s lack of appetite and loss of weight. Much fighting at home about habits. Sally claims to feel well and can’t see “ what all the fuss is about”. She just isn’t hungry.

Objective

• Wt. 48kg
• Pale, thin
• BP 100/60 Lying and standing
• Abdo and urinalysis unremarkable

Plan

• Review Sally alone
• Tests: FBE/TFT’s U+E/LFT’s

21/02/18
Subjective

• Distant, little eye contact. Feels parents are “overreacting”. Feels ideal weight is 40 kg ( currently 47kg). Denies vomiting. Vague about laxative use.
• Test Results: All normal

Assessment

• Anorexia Nervosa

Plan

• Refer to psychiatrist

Writing Task

Using the information in the case notes, write a letter of referral to the Psychiatrist Dr. Midori Yabe, 48 Wickham Tce, Spring Hill.

In your answer:

• Expand the relevant case notes into complete sentences

• Do not use note form

• The body of the letter should be approximately 180~200 words

• Use correct letter format

Answer:

Dr. Midori Yabe

48 Wickham Tce

Spring Hill

21 February 2018

Dear doctor,

Re: Sally Webster, DOB: 10/11/2001

I am writing to refer Ms. Sally, a high school student, who I believe has anorexia nervosa. (I don’t think you should present the diagnosis in the introduction.)

Ms. Sally was first presented to me about 2 months back with constipation of for the past three months duration. Her diet included two tablespoons of bran every morning and she had already tried laxatives then. (HAD = an event in the past. It includes then.) . Her pulse was normal, systolic blood pressure was 100 mm Hg and diastolic was 50 mm Hg. Her examinations were unremarkable and hence ,though she was taking two tablespoons of bran every morning and had already tried laxatives, she was advised to increase fiber and fluids in her diet. (I guess you should mention pulse and blood pressure. Make connections – she is already consuming stuff to cure her problem and you’re referring more of that. Write them together.)

Ms. Sally was again brought to me by her mother in two weeks’ time When she visited my clinic a week ago with her mother. She she had lost 6 kilograms, and looked pale and thin, and had a similar blood pressure reading. (Maintain parallelism in A, B, and C) While her mother was concerned about her loss of appetite, Sally claimed to feel well. On reviewing with Sally alone, she made very less eye contact and told that her parents were over-reacting (I don’t think her belief about her parents or that of her parents about her is important. Let us stick to doctor’s observations and facts. Though she claimed to feel well, she made little eye contact and believed that her ideal weight was 40 kilograms.). Furthermore, she told that her ideal body weight was even less, (let us keep observations and beliefs – ideal weight, eye contact, feel well – separate from facts – denied vomiting.) She denied vomiting and was vague in regards to the laxative use. All her blood tests were within normal range.

Based on my provisional diagnosis of anorexia nervosa, My provisional diagnosis is that she suffers from Anorexia Nervosa and I would like to refer her to you for further investigation. I would appreciate if you could take over her care for appropriate treatment.

Please do not hesitate to contact me should you have any further queries.

Yours sincerely,