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
Submit your OET letters for correction: (for a minimal fee)
https://goltc.in/oet-writing-correction/