Dr Jacob Kumar
Royal Darwin Hospital
Rocklands Drive, Tiwi
PO Box 41326, Casuarina NT 0811

22/01/2010

Dear Dr Kumar,
Re: Mrs. Lisa Bayliss,  06/01/1964

I am writing to refer Mrs. Bayliss, who is in need of assessment and palliative care. She is currently recovering from a grade 2 adenocarcinoma, which has metastasised to her lumbar spine.

On April 13, 2009, Mrs. Bayliss underwent various tests due to concerns about the possibility of breast cancer. Ultrasound confirmed the presence of a solid lump, and cytological examination revealed malignant cells. A core biopsy under local anaesthesia confirmed adenocarcinoma.

Subsequently, on May 4, 2009, Mrs. Bayliss underwent a local excision and axillary clearance, followed by radiotherapy to address residual tumour in her breast for local control. At that time, there was no evidence of metastases, and her hormone receptor status was negative. She was advised to undergo chemotherapy and regular review for metastasis as part of her post-operative recovery.

Today, Mrs. Bayliss reported a sudden onset of extreme, constant lower back pain, causing sleeplessness and loss of appetite, resulting in a weight loss of 4kg. The pain radiates down to major portions of her leg, and she exhibits no knee jerk reaction while her anterior thighs lack sensation. Assessment revealed metastases of the tumour to her lumbar spine.

Based on the above information, I kindly request an assessment and provision of palliative care for Mrs. Bayliss. She is scheduled to undergo a bone scan and CT scan of the chest and abdomen, as well as radiotherapy to manage the pain. If you require further information, please do not hesitate to contact me.

Yours sincerely,
Registered nurse.

Writing task:

TASK 47        Patient’s name           : Mrs. Lisa Bayliss                 

Date of Birth  : 6th January, 1964

Social History            : Married with 2 children, Heavy smoker, Drinks alcohol occasionally

Past Medical History: not relevant, no previous breast problem

Past Surgical History: Tubal ligation 8 years ago

Menstrual History: Menarche at the age of 11, Menstruation – normal flow, period regular, 3/28 cycle

Family History          : No family history of breast disease

13/04/2009     

Subjective      : noticed lump in upper part of right breast 2 months ago,

No change in size during menstrual cycle, no discharge from nipple

Objective        : pulse rate-76/min, BP-130/85, an III-defined 1.5 cm lump in upper quadrant of right breast, no lymph node enlargement, overlying skin-normal, no evidence of attachment to surrounding structures, no other abnormal findings on general examination

Assessment    :Breast cancer or Fibroadenoma or cyst

Plan    :Explain possible conditions & consequences, to undergo radiological assessment (Mammogram) and Pathological assessment (Fine needle aspiration or core biopsy)

Subjective      : extremely concerned about the possibility of cancer, difficult to sleep at night, anxious, feeling low, sometimes irritated, pounding heart, unable to cope even household chores, lack of concentration, breast lump-no problem.

Objective        :PR 85/min, BP 140/90, Look anxious, sweaty, other examinations –normal, Mammogram-normal, Ultrasound – confirmation of solid lump, Cytological examination – malignant cells, Core biopsy under local anesthesia-adenocarcinoma

Assessment    : Anxiety secondary to breast cancer (adenocarcinoma)

Plan: Break bad news, suggest to take further tests (blood tests, bone scan,CTscans) outline different treatment options available such as surgery radiotherapy and chemotherapy, to refer to general surgeon for operation.

4/05/2009        Subjective      : for regular follow-up, had local excision and axillary clearance with radiotherapy to residual right breast for local control

Objective        : general condition-well, no evidence of metastases, hormone receptor negative

Assessment : post-operation recovery of grade 2 adenocarcinoma

Plan    : chemotherapy, regular reviews for cancer spread, to contact local breast cancer foundation for further information

22/01/2010 Subjective : sudden onset of severe low back pain, suffering from mild back pain 4 weeks ago, constant pain, keeping her awake at right, exacerbated by movement, radiate down back of left leg, 4 kg weight loss, the pain “got rid of her appetite”

Objective : pain distribution in front of thigh, inner aspect of thigh, knee & leg, sensory loss in anterior aspect of thigh, absence of knee jerk

Assessment : Tumour spread to lumbar spine

Plan    : Bone scan, CT scan of chest & abdomen, radiotherapy to control pain, refer to an oncologist for assessment & palliative care

Writing Task Using the information in the relevant case notes, write a letter of referral to Dr. Jacob Kumar at the Royal Darwin Hospital, Rocklands Drive, Tiwi, PO Box 41326, Casuarina NT 0811