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LETTER 4

Letter-4(15/08/2020)


17 June,2018


Dr Ian Robson

Allergist

Central Hospital 

Oldtown


Dear Dr Robson,


Re:Mr Tom Riddle

DOB:19 May,1998


Mr Riddle,a 20 year-old student ,who has been diagnosed with asthma.,He requires further testing and identification of his allergies following his discharge today. 

  • Overall introduction is good except Last sentence as this patient is not admitted

  • Instead of writing the whole Introduction in one sentence,try to break it in two,this doesn't mean you were wrong.


Initially,on 01 June,2018,Mr Riddle presented to clinic with two-weeks history of breathlessness,persistent coughing,sneezing as well as eye itching which leads him to absence of classess.Consequently, relevant investigations were performed and he was treated with oral prednisone 50mg for10days,albuterol inhaler ,twice daily and symbicort.


Twelve days later,Mr Riddle came with sleep disturbance and eczema. On assessment,his vital parameters were abnormal ;therefore,oxygen therapy was administered to him

along with hourly albuterol and intravenous corticosteroids which resulted in a good progress. 

  • either oxygen can be administered or oxygen therapy can be provided or given

On today 'a s visit,Mr Riddle was educated about the environmental triggered factors and proper inhaler techniques.


Mr Riddle has a history of childhood asthma;however,no signs from the past 8years and periodic eczema .In addition,his grandfather is asthmatic. It is worthy to note, he recently moved into a new accommodation and lives with two cats.He sleeps on the dusty old carpet floor .


 Pertaining to the above information,kindly take over Mr Riddle's case and do required investigations. Please note,he needs environmental management guidance. 


Please do the needful and do not hesitate to contact me for further queries. 


Yours sincerely, 


Registered Nurse.


  • Good attempt except the mentioned mistakes 

  • interpretation and understanding of the casenote is inevitable 

  • From the first part of this case note we will get the hint that he was not admitted.

  • Best wishes!!!

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