CASE NOTES wITH SAMPLE aNSWERS – 40 sets

This includes 40 sets of case notes arranged as per its difficulty levels and their model answers, to prepare students well with letter writing flow. These samples are carefully written by our OET experts. 

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DESCRIPTION

The 40 sets of A-grade sample answers are perfect models for any authentic OET references. Our expert quality wing prepared all sample answers, taking special attention on linguistic and medical aspects of the OET exam. It is really handful for candidates preparing for OET exam aiming a score above 400.  All sample answers fully satisfy the criteria established by OET exam regulators 

SAMPLE CASE NOTE

The time allowed: 45 Minutes

Reading Time: 05 Minutes

Writing: 40 Minutes 

Read the case notes and complete the writing task, which follows.

Case Notes: 

Mr Tom Hanks is a 70-year-old patient under your supervision at the Massachusetts General hospital you are working. 

Patient Details: 

Patient: Mr Tom Hanks

Marital Status: Widower (7 years) 

Height: 1.75 m 

Background: Obese for years 

Related depression under medication since 2006

Family quarrel 

Call operator, busy work schedules and night shifts, irregular work schedule.

Chess player national level.

Patient History:

15/05/2010 

Subjective: Assessment reports exhausted, headache for last 8 hrs, highly anxious, feeling drowsiness occasionally during the examination, very stressed, vomited 3 times.

Objective: BP: 95/60, Heart rate 80 bpm

BMI: 31. 2 (weight 100 kg) 

Skin check– no lesions found, normal cervical spine movement.

Abdomen ex normal, no other health problems 

Tests: CBC, Cholesterol/Lipids, thyroid test, a fasting blood sugar.

Plan: Wait for test results, advised to take proper rest, analgesia is given, regular medication Fluoxetine continue, counsellor access to pt. 

20/05/2010

Subjective: Results of blood tests (Cholesterol/lipids, CBC) intermittent headaches, nausea and vomiting Fatigue, Reports weakness in Rt calf region, overstressed, Insomnia.

Objective: BP: 90/80, HR: 81 bpm.

The normal peripheral nervous system, Fluoxetine ongoing

BMI – 31.6

Test Results: Cholesterol 6.38 mmol/L (normal range is 5 mmol/L, (normal limit: under 5.0 mmol/L) – other results in normal range. 

Assessment: Repeat test Cholesterol, migraine possibility.

Monitor the patient’s general health, patient reports overtired, depressed.

Lifestyle modification recommended. 

Plan: Analgesia, diet modification, decreased fat, Obesity-specialist counselling and support

Exercise to ↓ Cholesterol level and weight. Reduce alcohol intake and stop smoking.

16/6/2010

Complains of unsteadiness and reports three recent blackouts.

Feel very stressed – busy at work, fluctuation of very occasional mood changes and disturbance, breathing difficulty and constipation, sleeplessness, ↑ depression, ↑ alcohol intake, and smoking.

Examination: BP 150/90, HR 75 bpm

BMI – 30

Loss of sensation in L & R hands 

Tests: NCV, nerve biopsy, Lumbar spinal CT Scan 

Assessment:? Multiple Sclerosis

Refer to Neurologist immediately for full neurological assessment and MRI. 

Writing Task:

Using the information in the case notes, write a letter of referral to Dr Simon Francis, Neurologist. USCSF Medical centre, Artfi Road, San Francisco, SF2 019.

In your answer: 

Expand the relevant notes into complete sentences 

Do not use note form. 

Use letter format 

The body of the letter should be approximately 180-200 words. 

END OF WRITING TEST

 

SAMPLE ANSWER

Dr Simon Francis 

Neurology Department 

USCSF Medical centre 

Artif Road

San Francisco 

SF2 019. 

(Today’s date)

Re: Mr Tom Hanks

Dear Dr Francis,

I am writing to refer Mr Tom Hanks, a 70 year- old call operator, who presented the hospital reporting extreme tiredness accompanied by loss of sensation in his left and right hand and right calf. An urgent neurological assessment of the patient is requested at your facility. 

Mr Hanks was admitted into the hospital citing drowsiness, headache (for about 8 hrs) and, vomiting episodes on 15 May 2010. During his first day at the hospital, his blood pressure and heart rate noted were 95/60 and 80 bpm, respectively.

He was given analgesia and was asked to bed rest for a few days.

The follow-up review, a week later, provided no definitive cause for his condition. All test results were normal except the cholesterol level (6.38mmol/L). Tom was advised to continue with the analgesia, along with his regular antidepressant medication. He was encouraged to both increase his exercise levels and, lower his fat through diet modification. The service of obesity-specialist was also made available.

On 16th June again, he complained of experiencing unsteadiness and blackouts along with breathlessness and constipation. His blood pressure also showed a slight increase from 95/60 to 150/90. As per the provisional diagnosis, the condition assessed was possible multiple sclerosis, and lumbar spinal CT scans have been ordered accordingly.

It would be greatly appreciated if you could conduct an emergency full neurological assessment at the earliest.

Please contact me with any queries.

Yours sincerely 

Charge Nurse

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