Sample letter by Lifestyle Training Centre

Neurologist,
Emergency department

15 / 5 / 2011

Dear Sir/Madam,
Re: Ms Maria Joseph, aged 39 years.

I am writing to refer Ms Joseph who requires your urgent assessment and care in the emergency department. She is suspected to have intracranial pathology and space occupying lesions, following a fall at home, due to severe left sided headache.

Ms Joseph’s vitals are slightly high: P 100, BP 150/90. She is half unconscious, and her speech is slightly slurred. There are bruises on her left leg and injury on her right arm: extension 4/5 power and left leg knee flexion 4/5.

Ms Joseph had first visited our hospital on 10/5/2011 due to frontal headache of 6 hours, suffering from nausea and blurred vision. She was advised to take rest and was given paracetamol, 500, q4h. She has no family history of migraine and was suspected to be suffering from excess tension or personal dilemma.

On 14/5 /2011, she reported of persistent left sided and frontal headaches, blurred vision and throbbing left sided headache. She had vomited 5 times within three hours and had complaints of slight paraesthesia. Her vitals were slightly abnormal and she was distressed. On account of severe migraine possibility, Pethidine, 100 mg and intramuscular injection of Maxolon, 10 mg were prescribed.

Based on the above, kindly assess and provide urgent treatment to Ms Joseph in the emergency department. If you require further information, please do not hesitate to contact me.

Yours faithfully,
Registered Nurse.

Word count:210

Writing task

TASK –73: Patient: Maria Joseph is a 39 years old woman who has been a patient at a hosptical you are working in as a head nurse. Apart from usual childhood illness such as chicken pox, she had been healthy.

10 / 5 2011: Subjective: Frontal headache for 6 hrs. Mild assoc, suffering from nausea, no vomiting, patient with blurred vision but not aura. No other symptoms noticed. She has no family history of migraine.

Objective P96, BP 130/ 70. Normal Cervical Spine Movement, examination normal.

Assessment Probably due to excess tension or personal dilemma

Plan Advised to take rest. Given analgesia (paracetamol (500q4h))

14/5 /2011: Subjective Complained of continuous headaches (left sided and frontal), blurred vision, throbbing headache (left sided). Vomited 5 times during last three hours Complaining of slight paraesthesia.

Objective Distressed, P 103, BP 150/90, Normal peripheral nervous system

Assessment Severe Migraine Possibility

Plan: Stat- Pethidine 100 mg, intramuscular injection Maxolon 10 mg

15 / 5 / 2011: Home Visit: Subjective Fell down at home due to severe left sided headache, started some 5 hrs after reaching home. Injured her right arm, bruises on left leg. slurred speech, half unconscious.

Objective P 100, BP 150/90, extension 4/5 power, left leg knee flexion 4/5

Assessment Probable intracranial pathology, space occupying lesions.

Plan Urgent assessment in Emer. Dept.

Writing task: Using the information given above write a letter to the neurologist, who will attend the patient in the emergency department.

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