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James Warden A

James Warden, an 80-year-old widower, presents with a bilateral inguinal hernia. He was initially diagnosed with a right inguinal hernia 3 months ago and advised to avoid heavy lifting and reduce his alcohol intake. However, the swelling has increased after lifting a wheelbarrow. Examination now shows a considerable swelling in the right groin and a mild swelling in the left groin. The GP refers Mr. Warden to a surgeon but notes that the patient wishes to have the hernia surgery under local rather than general anesthesia.

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prakash poudel
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479 views3 pages

James Warden A

James Warden, an 80-year-old widower, presents with a bilateral inguinal hernia. He was initially diagnosed with a right inguinal hernia 3 months ago and advised to avoid heavy lifting and reduce his alcohol intake. However, the swelling has increased after lifting a wheelbarrow. Examination now shows a considerable swelling in the right groin and a mild swelling in the left groin. The GP refers Mr. Warden to a surgeon but notes that the patient wishes to have the hernia surgery under local rather than general anesthesia.

Uploaded by

prakash poudel
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
You are on page 1/ 3

Read the cases notes below and complete the writing task which follows

Time allowed: 40 minutes

Today's Date

25.08.09

Patient History
James Warden

DOB 05.07.29

Regular patient in your General Practice

09.07.09
Subjective
Wants regular check up, has noticed small swelling in right groin.
Hypertension diagnosed 5 years ago, non smoker, regularly drinks 2 – 4 glasses of wine
nightly and 1 - 2 glasses of scotch at weekend.
Widower living on his own ,likes cooking and says he eats well.
Current medication noten 50 mg daily, ½ aspirin daily, normison 10mg nightly when
required, fifty plus multivitamin 1 daily, allergic reaction to penicillin.

Objective
BP 155/85 P 80 regular
Cardiovascular and respiratory examination normal
Urinalysis normal
Slight swelling in right groin consistent with inguinal hernia.

Plan
Advised reduction of alcohol to 2 glasses maximum daily and at least one alcohol free
day a week.
Discussed options re hernia. Patient wants to avoid surgery.
Advised to avoid any heavy lifting and review BP and hernia in 3 months

25.08.09
Subjective
Had problem lifting heavy wheelbarrow while gardening. Has a regular dull ache in
right groin, noticed swelling has increased.
Has reduced alcohol intake as suggested.
Objective
BP 140/80 P70 regular
Marked increase in swelling in right groin and small swelling in left groin.

Assessment
Bilateral inguinal hernia
Advise patient you want to refer him to a surgeon. He agrees but says he wants a
local anaesthetic as a friend advised him he will have less after effects than with general
anaesthetic.

Writing Task

Write a letter addressed to Dr. Glynn Howard, 249 Wickham Tce, Brisbane, 4001
explaining the patient's current condition.

In your answer:

Expand the relevant case notes into complete sentences


Do not use note form
The body of the letter should not be more than 200 words
Use correct letter format
Sample Model Letter 4

25/08/2009

Dr. Glynn Howard


Surgical Department,
249 Wickham Tce,
Brisbane 4001

Dear Doctor,

Re: Mr. James Warden


DOB 05/07/29

I am referring this patient, a widower, who is presenting with symptoms consistent with a
bilateral inguinal hernia. He has been suffering from hypertension for 5 years for which
he takes Noten, Aspirin and multivitamins. He is allergic to penicillin.

Initially Mr Warden presented to me on 09/07/09 for a regular check up. On examination


he had a mild swelling of the right groin, his blood pressure was 155/85 and pulse was 80
beats per minute, otherwise his condition was normal. He was diagnosed as having an
inguinal hernia. I discussed the possibility of surgery, however he indicated he did not
want an operation. Therefore I advised that he avoid heavy lifting and reduce alcohol
consumption. A review consultation was scheduled for 3 months later.

Today he returned complaining that his right groin had increased in size with a regular
dull ache possibly due to lifting a heavy wheel barrow. The examination revealed a
considerable increase in the swelling in the right groin as well as a mild swelling of the
left groin.

Based on my provisional diagnosis of a bilateral inguinal hernia, I would like to refer him
for surgery as early as possible. Please note that wishes to have the surgery under local
anaesthesia.

Yours sincerely,

Dr X (GP)

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