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  • Read The Case Notes Below and Complete The Writing Task Which Follows

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    Vivek Agrawal
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    Mr Brett Collister is a 44-year-old factory foreman who has been experiencing fatigue, sore eyes and dizziness over the past few months. His blood test results indicate type 2 diabetes with high glucose, HbA1c and cholesterol levels. As his general practitioner, I am referring him to Dr. Grantley Cross, an endocrinologist, for further assessment and a diabetes management plan.

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    Brett Collister

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    Mr Brett Collister is a 44-year-old factory foreman who has been experiencing fatigue, sore eyes and dizziness over the past few months. His blood test results indicate type 2 diabetes with high glucose, HbA1c and cholesterol levels. As his general practitioner, I am referring him to Dr. Grantley Cross, an endocrinologist, for further assessment and a diabetes management plan.

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    © All Rights Reserved
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    302 views2 pages

    Read The Case Notes Below and Complete The Writing Task Which Follows

    Uploaded by

    Vivek Agrawal
    Mr Brett Collister is a 44-year-old factory foreman who has been experiencing fatigue, sore eyes and dizziness over the past few months. His blood test results indicate type 2 diabetes with high glucose, HbA1c and cholesterol levels. As his general practitioner, I am referring him to Dr. Grantley Cross, an endocrinologist, for further assessment and a diabetes management plan.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 2

    Read the case notes below and complete the writing task which follows.

    Notes:

    Mr Brett Collister is a male patient in your general practice.

    PATIENT DETAILS:

    Name: Mr Brett Collister (DOB: 21 December 1973)

    Height: 177cm

    Occupation: Factory foreman

    Social background: Married, 3 children (18, 16, 13 yrs)

    Hobbies: Watching football, playing darts, fishing

    Medical history: No known allergies

    Infectious mononucleosis – February 2006

    Treatment record

    22/04/17 Productive cough & sore throat for 1 week, green phlegm.

    Pt tired, temp (38°C).

    Treatment: Rest, plenty of fluids, salt water gargles.

    26/06/17 Sore throat – suddenly worse after 3 weeks of intermittent pain & fever; Pt feels ‘run-down’.

    Tonsils inflamed; temp 38.5°C.

    Treatment: Prescribed amoxicillin.

    17/09/17 Sore L shoulder – triggered during game of darts 2 weeks previous − ?rotator cuff tear.

    Busy at work – feels tired & stressed.

    Treatment: Prescribed ibuprofen.

    R.I.C.E. (rest, ice, compression, elevation).

    Refer to physio for exercise program & treatment for shoulder.

    26/11/17 Sore R knee – pain intermittent, worse going up stairs. No identified trigger.

    ?osteoarthritis.

    Shoulder has improved.

    BP 107/60, HR 78 (reg), Wt 94kg (BMI 30 – overweight).

    Treatment: Prescribed ibuprofen.

    Advised to weight, exercise (cycling, swimming).

    Refer to physio (as previously) – review in 3 months.

    04/02/18 Pt feels tired, ‘run-down’; sore eyes, dizzy sometimes (for last 3-4 weeks) – ?orthostatic hypotension.

    Overweight, unfit – no adjustment to lifestyle, diet, exercise.

    Reports busy at work.

    BP 108/61, HR 80 (REG), lungs clear, Wt. 93 kg(BMI 29.7 -overweight)


    Treatment: Order blood tests to review cholesterol, blood sugars, etc.

    24/02/18 Still tired, sore eyes, vision .

    BP 105/60, HR (reg), lungs clear, Wt 89kg ( BMI 28.4 – overweight).

    Review of tests organised 04/02/18:

     random glucose 3.5mmol/L (high).


     fasting glucose 7.4mmol/L (high).
     Hba1c 8.5% (high).
     HDL/LDL (cholesterol 6.4mmol/L, LDL 4.2mmol/L, HDL 2.1mmol/L, Trig 3.3mmol/L).

    Preliminary diagnosis: Results indicate DM (diabetes mellitus) Type 2.

    Treatment: Refer to endocrinologist for assessment and management plan.

    Writing Task:

    Using the information in the case notes, write a letter of referral to Dr Grantley Cross, an endocrinologist, requesting

    assessment and a management plan. Address your letter to Dr Grantley Cross, Consultant Endocrinologist, City
    Hospital, Suite 32, 55 􀀴ain Road, Newtown.

    In your answer:

    􀀴 Expand the relevant notes into complete sentences

    􀀴 Do not use note form

    􀀴 Use letter format

    The body of the letter should be approximately 180–200 words.

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