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Reading Sample Test 1 Text Booklet Part A

Alison Martin, a 28-year-old teacher, has been experiencing symptoms of depression including fatigue, lack of motivation, poor concentration, anxiety, and headaches. Her relationship with her mother-in-law is strained and she feels the mother-in-law is turning her husband against her. On her most recent visit, accompanied by her husband, she displayed disorganized speech, bizarre behavior, and reported visual hallucinations and delusions over the past five days. Based on her symptoms, her GP Dr. Ivan Henjak believes she is likely experiencing schizophrenia and refers her to psychiatrist Dr. Peta Cassimatis for further assessment and management.

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103 views

Reading Sample Test 1 Text Booklet Part A

Alison Martin, a 28-year-old teacher, has been experiencing symptoms of depression including fatigue, lack of motivation, poor concentration, anxiety, and headaches. Her relationship with her mother-in-law is strained and she feels the mother-in-law is turning her husband against her. On her most recent visit, accompanied by her husband, she displayed disorganized speech, bizarre behavior, and reported visual hallucinations and delusions over the past five days. Based on her symptoms, her GP Dr. Ivan Henjak believes she is likely experiencing schizophrenia and refers her to psychiatrist Dr. Peta Cassimatis for further assessment and management.

Uploaded by

pratim dey
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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Task 9 Case Notes: Alison Martin

Time allowed: 40 minutes


Read the case notes below and complete the writing task that
follows:

Today’s Date
10/02/10

Patient History

Alison Martin
Female
28 year old, teacher.
Patient in your clinic for 10 years
Has 2 children, 4 years old and 10 months old, both pregnancies
and deliveries were normal. Husband, 30 yr old, manager of a
travel agency. Living with husband’s parents.
Has a F/H of schizophrenia, symptoms controlled by Risperidone
Smoking-nil
Alcohol- nil
Use of recreational drugs – nil

09/01/10

Subjective

c/o poor health, tiredness, low grade temperature, unmotivated at


work, not enjoying her work. No stress, loss of appetite or weight.

Objective

Appearance- nearly normal


Mood – not depressed
BP- 120/80
Pulse- 80/min
Ab, CVS, RS, CNS- normal

Management

Advised to relax, start regular exercise, and maintain a temperature


chart. If not happy follow up visit required

20/01/10

Subjective
Previous symptoms – no change
Has poor concentration and attention to job activities, finding living
with husband’s parents difficult. Says her mother-in-law thinks she
is lazy and is turning her husband against her. Too tired to do much
with her children, mother-in-law takes over. Feels anxiety, poor
sleep, frequent headaches.

Objective

Mood- mildly depressed


Little eye contact
Speech- normal
Physical examination normal

Tentative diagnosis

Early depression or schizophrenia

Management plan

Relaxation therapy, counselling


Need to talk to the husband at next visit
Prescribed Diazepam 10mg/nocte and paracetamol as required
Review in 2/52

10/02/10
Subjective

Accompanied by husband and he said that she tries to avoid eye


contact with other people, reduced speech output, impaired
planning, some visual hallucinations and delusions for 5 days

Objective

Mood – depressed
Little eye contact
Speech – disorganised
Behaviour- bizarre
BP 120/80
Pulse- 80
Ab, CVS, RS, CNS- normal

Probable diagnosis

Schizophrenia and associated disorders


Management plan

Refer to psychiatrist for assessment and further management.

Writing Task
You are the GP, Dr Ivan Henjak. Write a referral letter to
Psychiatrist, Dr. Peta Cassimatis: 1414 Logan Rd, Mt Gravatt, 4222.
In your letter expand the relevant case notes into complete
sentences. Do not use note form. The body of your letter should be
approximately 200 words. Use correct letter format.

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