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NEW CASE NOTE-MR ANDREW MC ALLISTER


Today's Date
20.01.25

Patient History
Name: Andrew McAllister
DOB: 15.03.1973
Regular Patient: Your General Practice for the past 6 years.

15.12.24

Subjective

  • Presented for routine check-up.
  • Complained of mild discomfort and occasional swelling in the right groin.
  • Diagnosed with Type 2 Diabetes (4 years ago), managed with oral hypoglycemics.
  • History of hypertension (7 years) – controlled.
  • Social habits: Non-smoker, consumes 3–4 glasses of wine daily, occasional whiskey on weekends.
  • Lives alone, employed as a construction supervisor.
  • Diet: Balanced, enjoys cooking but occasionally skips meals due to workload.

Medications:

  • Metformin 500mg twice daily.
  • Amlodipine 10mg daily.
  • Aspirin 75mg daily.
  • Vitamin D supplement daily.

Allergies:

  • Allergic to penicillin (rash, itching).

Objective

  • BP 150/90; P 76, regular.
  • Slight swelling in the right groin indicative of early inguinal hernia.
  • Cardiovascular, respiratory, and abdominal exams normal.
  • Blood glucose: Slightly elevated (HbA1c: 7.3%).

Plan

  • Advised weight management and reduction in alcohol consumption.
  • Suggested avoiding heavy lifting at work.
  • Discussed hernia management options – patient reluctant to consider surgery.
  • Scheduled a follow-up in 4 months to reassess hernia and blood pressure.

20.01.25

Subjective

  • Returned with worsening groin discomfort.
  • Struggled while lifting a toolbox at work.
  • Now experiencing a persistent ache and significant swelling in the right groin.
  • Noticed a smaller swelling in the left groin.

Lifestyle Changes:

  • Reduced wine consumption to 2 glasses daily, avoids whiskey.
  • Slight improvement in weight (lost 2 kg in 4 months).

Objective

  • BP 145/85; P 72, regular.
  • Right groin: Marked increase in swelling with tenderness; consistent with worsening hernia.
  • Left groin: Small but noticeable swelling, indicative of early hernia.

Assessment

  • Bilateral inguinal hernias.
  • Advised surgical intervention to prevent further complications.

Plan

  • Referral to surgeon. Patient prefers local anesthetic after consulting a friend who shared experiences of fewer post-operative effects.
  • Ensure surgeon is informed of patient’s penicillin allergy and history of diabetes.

Writing Task

Write a referral letter to Dr. Glynn Howard, 249 Wickham Tce, Brisbane, 4001, explaining Andrew McAllister's current condition and relevant medical history.

In your answer:

  • Expand the relevant case notes into complete sentences.
  • Do not use note form.
  • Ensure the letter body does not exceed 200 words.
  • Use the correct letter format.

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