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Darren Walker

Darren Walker is a 40-year-old man who presents with discomfort urinating and an enlarged prostate. His PSA level is elevated at 10. He has a family history of prostate cancer. He is referred to an urologist, Dr. David Booker, for further investigation which may include a prostate biopsy. The referral letter asks to be informed of the outcome of the urologist's examination and any further tests.

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Hafni Kumar
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193 views

Darren Walker

Darren Walker is a 40-year-old man who presents with discomfort urinating and an enlarged prostate. His PSA level is elevated at 10. He has a family history of prostate cancer. He is referred to an urologist, Dr. David Booker, for further investigation which may include a prostate biopsy. The referral letter asks to be informed of the outcome of the urologist's examination and any further tests.

Uploaded by

Hafni Kumar
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Task 5 Case Notes: Darren Walker

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

Time allowed: 40 minutes

Today's Date

15.08.09

Patient History
Darren Walker

DOB 05.07.69

Regular patient in your General Practice

09.07. 09
Subjective
Regular check up, Family man, wife, two sons aged 5 and 3
Parents alive - father age 71 diagnosed with prostate cancer 2002.
Mother age 68 hypertension diagnosed 1999.
Smokes 20 cigarettes per day –trying to give up
Works long hours – no regular exercise
Light drinker 2 –3 beers a week

Objective
BP 165/90 P 80 regular
Cardiovascular and respiratory examination normal
Height 173 cm Weight 85kg
Urinalysis normal

Plan
Advise re weight loss, smoking cessation
Review BP in 1 month
Request PSA test before next visit

14.08.09
Subjective
Reduced smoking to 10 per day
Attends gym twice a week, Weight 77 kg
Complains of discomfort urinating

Objective
BP 145/80 P76
DRE hardening and enlargement of prostate
PSA reading 10
Plan
Review BP, smoking reduction in 2 months
Refer to urologist – possible biopsy prostate

Writing Task

Write a referral letter addressed to Dr. David Booker (Urologist),


259 Wickham Tce, Brisbane 4001. Asl to be informed of the
outcome.

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

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