Sample letter by Lifestyle Training Centre

20/08/2022

Mr Charles requires your expert assessment, following his discharge today. He was diagnosed with Hepatitis B and underwent treatment in our hospital.

Mr Charles was admitted to our hospital on 02/08/2022 with various complaints: fatigue, nausea, poor appetite, belly pain, mild fever and Jaundice. Ultrasound scans of the liver as well as Hepatitis B blood panel were carried out to confirm the afore mentioned diagnosis.

During hospitalization, administration of Baraclude, 0.5mg, once daily; and Vitamin E, 300mg, twice daily were started. Paracetamol and Ibuprofen, 500mg, 3 times a day, were given to treat his high fever and severe stomach pain. At present, Mr Charles has better appetite, and the Jaundice is reduced. However, he still suffers from increased fatigue, nausea as well as intermittent belly pain.

Mr Charles is a university athlete. He has medical histories of Measles, Chicken pox and was hospitalized for Gastritis in 2010. He has been suffering from Hepatitis A for the past 7 years. He also has family history of Hypertension, Heart attack and Pneumonia.

Based on the above, please assess Mr Charles to further evaluate his condition. He is given a specific diet and exercise plan. He should continue his medication and vitamins for 3 months. Should you have further queries, please do not hesitate to contact me.

(Words count: 193)

           

 Writing task. 

Case notes: 

Name of the patient: Louis Charles 

Age: 22 years 

Admission: August 2, 2014 

Discharge: August 20, 2014 

Social Background: 

University athlete 

Orphan 

Single 

John Laden-best friend 

Lives at the athlete’s university quarters. 

Diagnosis: Hepatis B 

Complaints: 

Fatigue, nausea, poor appetite, belly pain, a mild fever, or yellow skin or eyes (jaundice) 

Ultrasound scan of the liver: 

Blood test, hepatitis B is first diagnosed using a blood test that looks for a certain antigen (fragments of H8V) and antibodies (produced by immune system in response to HBV). The test is called a Hepatitis B blood panel, and it checks for the following. 

HBsAg (the hepatitis B surface antigen) 

AntiHBs (antibodies to the HBV surface antigen) 

AntiHBc (antibodies to the HBV core antigen) 

Treatment: 

BARACLUDE 0.5 mg once daily for 3 months, taken on empty stomach (at least 2 hours after a meal and 2 hours before the next meal). 

Vitamin E 300mg twice daily for 3 months. 

Complications: 

Severe stomach pains. High fever-paracetamol and Ibuprofen 500mg 3x a day as needed. 

Medical history

Hepatis A (7 years old) 

Measles and chicken pox 

Gastritis (2010 hospitalized) 

Family History 

Hypertension 

Heart attack 

Pneumonia 

Progress: 

To more fatigue and nausea 

Improved appetite, fever and yellow skin or eyes (jaundice) has lessened 

Belly pain once in a while 

Discharge plan 

Lifestyle: 

Carbs: Fruits and veggies, skip the sweets and alcohol. 

Protein: lean meats, palfrey, fish, bears, eggs, nuts, seeds, milk, yogurt and cheese. 

Exercise 3 times a week at least 30 minutes. 

Medication and follow-up check. 

Description and vitamins to continue for 3 months. See a Hematologist for further evaluation. 

Writing task: 

Using the information in the case notes, as a charge nurse of Holy Angels Medical Centre, write a referral letter to Dr James Harry, Hepatologist of the Spring Dawn Hospital, 1102 Riverbank Road, New South Wales, Australia for further evaluation of Mr. Louis Charles. 

In your answer: 

 Expand the relevant case notes into complete sentences. 

 Do not use note form. 

 The body of the letter should be approximately 200 words. 

 Use correct letter format.

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