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NEW WRITING CASE NOTE - JOHN ADAMS


Writing Task
Using the information provided below, write a letter to Dr. Laura Perkins, General Practitioner, at HealthFirst Medical Centre, requesting follow-up care for Mr. John Adams after his hospital admission. Include the relevant medical history, treatment provided, and any ongoing care requirements.

Patient Details:

  • Name: John Adams
  • Age: 67 years
  • Address: 34 Hawthorn Avenue, Bristol

Medical History:

  • Diagnosed with an abdominal aortic aneurysm (AAA) three months ago (routine check-up).
  • Smoker for 30 years; ceased smoking post-diagnosis.
  • Hypertension, managed with ramipril 5 mg daily.
  • Type 2 diabetes, controlled through diet.

Social History:

  • Lives alone; limited mobility.
  • Daughter visits twice a week.

Admission Details:

  • Date of Admission: 12 January 2025 (Emergency).
  • Presenting Complaint: Sudden onset of severe abdominal pain radiating to the back.
  • Diagnosis: Ruptured abdominal aortic aneurysm.
  • Management:
    • Emergency open surgical repair performed.
    • ICU stay: 3 days.
    • Transferred to the general ward: 15 January 2025.
    • Discharge planned: 19 January 2025.

Hospital Progress:

  • Post-operative recovery uneventful.
  • Wound healing well; staples intact.
  • Blood pressure stabilized (average 130/80 mmHg).
  • Blood glucose levels monitored: stable.

Discharge Plan:

  • Pain management: Paracetamol 1g 4 times daily as needed.
  • Wound care: Dressing changes every 3 days.
  • Follow-up with vascular surgeon in 6 weeks.
  • Physiotherapy referral for mobility improvement.
  • Encourage smoking cessation counseling.

Special Notes:

  • Monitor for signs of infection or complications (e.g., fever, redness around the wound).
  • Reinforce diabetes management strategies to prevent complications.

Candidate Instructions:

  • Do not use note form.
  • Ensure the letter is between 180–200 words.
  • You should address the letter to Dr. Laura Perkins.

Hints for Complexity:

  • Include information on both acute and chronic conditions.
  • Balance the urgency of follow-up care with long-term disease management.
  • Avoid overly simple phrasing; structure sentences with precision.

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