22 February 2025 OET Exam Sample Writing Case Note

Case note

Date: 22 February 2025

Patient Name: Ms. Johnston

Age: 85 years

Reason for Visit: Review of right foot burn and new concerns.

Presenting Complaint:

09/02/2025 (Emergency department)

Accompanied by son, with a right foot burn caused by hot water.

Treatment administered.

Discharged home with a follow-up appointment scheduled at the same practice.

12/02/2025 (At same practice)

Visit for follow-up.

Wound reported as well.

Patient stable.

22/02/2025 (At same practice)

Patient reports increased pain in the right foot, frustration, low mood, and depression.

Reduced mobility due to pain.

Objective:

Redness observed around the wound on the right foot.

Swelling noted all over the right foot.

Wound infection??. Swab taken for culture.

Subjective:

Son leaving abroad – three months for work.

Difficulty with climbing stairs, cooking, driving, and other Activities of Daily Living (ADLs).

Expresses worry about managing alone and feeling isolated.

Past Medical History:

Hypertension, managed with Amlodipine 5mg daily. BP 135/80 mmHg on 12/02/2025.

Possible mild cognitive impairment (reported by son).

Previous fall 6 months ago.

No known allergies.

Social History:

Lives with son in a two-story house.

Widowed for 5 years.

Son is primary caregiver.

Enjoys reading and light gardening.

Relies heavily on son for practical support.

Plan:

Discuss home support options with the Doctor. Patient agreeable to exploring this.

Explore the possibility of a Doctor’s home visit.

Monitor wound for infection pending swab results.

Consider review of pain management.

Address patient’s low mood and potential social isolation.

Writing Task:

Using the case notes provided, write a letter to Dr. Claire Brown, Ms. Johnston’s General Practitioner, outlining her current situation, highlighting the concerns regarding her right foot wound and her social circumstances, and requesting consideration for home support and a potential home visit.