TASK 12 Today’s Date 25.08.09. Name: James Warden
Patient History: DOB 05.07.09 Regular patient in your General Practice
09.07.09: Subjective: Wants regular checkup, has noticed small swelling in right groin. Hypertension diagnosed 5 years ago, non-smoker, regularly drinks 2-4 glasses of wine nightly and 1 – 2 glasses of scotch at weekend.
Widower living on his own, likes cooking and says he eats well. Current medication noten 50 mg daily,1⁄2 Aspirin daily, normison 10mg nightly when required, fifty plus multivitamin 1 daily, allergic reaction to penicillin.
Objective: BP 155/85 P 80 regular. Cardiovascular and respiratory examination normal Urinalysis normal
Slight swelling in right groin consistent with inguinal hernia.
Plan: Advised reduction of alcohol to 2 glasses maximum daily and at least one alcohol free day a week.
Discussed options re hernia. Patient wants to avoid surgery.
Advised to avoid any heavy lifting and review BP and hernia in 3 months
25.08.09 Subjective: Had problem lifting heavy wheelbarrow while gardening.
Has a regular dull ache in right groin, noticed swelling has increased. Has reduced alcohol intake as suggested
Objective: BP 140/80 P70 regular. Marked increase in swelling in right groin and small swelling in left groin
Assessment: Bilateral inguinal hernia
Advise patient you want to refer him to a surgeon. He agrees but says he wants a local anesthetic as a friend advised him he will have less after effects than with general anesthetic.
Writing Task: Write a letter addressed to Dr. Glynn Howard, 249 Wickham Tce, Brisbane, 4001 explaining the patient’s current condition.
Submit your OET letters for correction: (for a minimal fee)
https://goltc.in/oet-writing-correction/