OET WRITING CASE NOTE- Mr ROBERT WILSON

 OET Writing Task

Case Notes:

Patient Details:

• Name: Mr. Robert Wilson
• DOB: 22 June 1958 (65 years old)
• Address: 12 Greenway Road, Sydney

Presenting Complaint:

• Brought to the emergency department today by his daughter due to increasing confusion and agitation over the past two days.
• Reports of occasional headaches and dizziness for the past week.
• No history of falls or head trauma.

Medical History:

• Hypertension (diagnosed 10 years ago, on Amlodipine 5mg daily).
• Type 2 Diabetes Mellitus (diagnosed 8 years ago, on Metformin 500mg twice daily).
• No known allergies.

Social History:

• Lives alone; daughter visits weekly.
• Smoker (20 pack-years).
• Alcohol: occasional consumption.

Examination Findings:

• BP: 160/95 mmHg
• HR: 78 bpm, regular
• Temp: 37.1°C
• Neurological exam: Disoriented to time and place, no focal deficits.
• Blood glucose: 9.2 mmol/L.

Impression:

• Suspected hypertensive encephalopathy or possible metabolic cause of confusion.

Plan:

• Admit for observation and further investigations.
• Blood tests (CBC, renal function, electrolytes, blood glucose).
• CT brain scan to rule out stroke or other pathology.
• Neurology consultation requested.

Writing Task:
Using the information provided in the case notes, write a letter to Dr. Susan Harper, a neurologist at City Neurology Clinic, requesting urgent assessment and further management of Mr. Wilson. Address the letter to:

Dr. Susan Harper
Neurologist
City Neurology Clinic
25 Park Street, Sydney