Arthur Benson OET Case Notes

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

Today’s date: 12/09/17

Patient history

Arthur Benson

DOB: 15/04/92

Computer programmer

Regularly works 55-60 hr / week

Married with twin boys aged 6 months

Non-smoker and social drinker

Father died at 69 due to stroke

Mother is a diabetic on metaformin

P.M.H

Asthma since childhood – on steroid inhaler

Allergic to penicillin

25/08/17

Subjective

C/O headache (2/12) mild sensation of pins and needles, no nausea or vomiting

Had a car accident 3 months ago. Hospitalized and discharged after 24 hrs with no complications.

CT scan normal

Objective

O/E overweight BMI 32

Gait normal, has lumbar lordosis

Mild weakness in L/hand

Vision – good

Plan

Review 2/52

Panadol 2 tab 4/24 and rest 2/52

Advise to reduce weight and increase exercise

06/09/17

Subjective

Feeling better, no new complaints, no worsening of pins and needles sensation

Has been walking 30 minutes 3 times a week

Advised to start work and come back if any concern

Objective

Weight loss 3kg

12/09/17

Subjective

C/O worsening headaches for 3 days, dizziness, nausea, blurred vision

Pain not responded to Panadol but noticed mild response to Panadeine Forte

Objective:

No weight change

Gait normal

Could not read 2 line of eye chart

Edematuous optic disk on fundus examination

BP – 160/70

PR: 98bpm

Mild weakness and loss of sensation in medical aspects of L/hand

Reflexes: Elbow normal, wrist – no reflexes

Diagnosis – subdural haematoma

You are a General practitioner at a suburban clinic. Arthur Benson and his family are regular patients. Using the information in the case notes, write a letter of referral to a neurosurgeon for MRI scan. Address the letter: Dr J Howe, Neurosurgeon, Spirit Hospital

Grade B letter sample

Dr. J Howe

Neurosurgeon

Spirit Hospital

Wooloongabba

September 12th, 2017

Dear Dr. Howe,

Re: Mr. Arthur Benson, D.O.B. April 15th, 1992

I am writing to refer a 25-year-old man who has signs and symptoms indicative of subdural hematoma probably from an involvement in a car crash. Your urgent assessment and management of his condition by arranging a brain MRI would be highly appreciated.

Today, Mr. Benson presented to my clinic with a 3-day history of worsening headache accompanied by dizziness, nausea and blurred vision for which he found Panadol unhelpful.

Upon examination, he was found to be hypertensive with BP at 160/70. Other significant findings were mild weakness with numbness in the left hand and an absence of the reflex responses from both wrist tapping. Strikingly, he could not read the eye chart completely and his optic disc was found to be swollen on ophthalmoscopy.

Mr. Benson visited here about 3 weeks earlier complaining of a headache that he had been suffering for two months and tingling sensation without nausea or vomiting. Three months ago, he had had a 24-hour admission because of a car accident involvement. The remarkable findings were obesity, lumbar lordosis and mild weakness in his left hand. His brain CT scan was unremarkable. He was prescribed Panadol 2 tablets 4 times daily and was advised to take 2 weeks’ medical leave. Additionally, he was told to reduce weight and do more exercise. He reportedly had no new complaints and showed some partial improvement of the symptoms during the follow-up visit. He was advised to resume work.

Mr. Benson, an over-worked computer programmer, is married with 2 children. He has asthma and is on steroid inhaler. His family history is remarkable with stroke and diabetes. He does not smoke but drinks alcohol occasionally. Please note that he is allergic to penicillin.

Please do not hesitate to contact me if you need more information.

Yours sincerely,

Doctor

Manjusha Nambiar

Hi, I'm Manjusha. This is my blog where I give IELTS preparation tips.