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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