Case Notes
Today’s date: 7 July, 2017
You are the school nurse at Villalong State High School. A 16 year-old student has been sent to
see you by his teacher because of concerns about continuing weight loss. His parents had also
spoken to you about the issue a month ago.
Patient Details
Jason Cassini
DOB: 24 May 2001
Aged: 16
18 Vesper Street, Villalong, NSW
Social Background
Jason lives with his parents and two siblings (both sisters)
Both parents of Italian background – mother tends to be protective
Both parents work full-time
described by mother as ‘a quiet boy, with a few friends’
Medical History
No known allergies
normal birth
previously healthy – weight within normal percentiles for age
Glue ear as a child (5 years old)
# right forearm (10 years old) – fell out of a tree.
Recent Medical History
February, 2017- beginning of new school year. Jason returned from holiday in Italy, visiting
relatives and was noted to have put on a little bit of weight. Form teacher witnessed ‘goodnatured teasing’ from other students. Jason was upset by this and stated that the teacher did
not address the problem.
Early March, 2017 – Jason seen exercising intensively (running, performing push-ups) during
school lunch breaks. When questioned, Jason claimed to have eaten his lunch before exercising.
April, 2017 – meeting with Jason’s mother – concerned about son’s weight loss and refusal to
eat meals with family. Offered to speak with Jason – meeting with Jason unproductive, refused
to admit diet restricted or over-exercising.
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June, 2017 – form teacher contacted me, concerned about Jason’s continuing weight loss. Now
appears fatigued during class time, but continues extreme exercise programme. Tried to
contact parents without success to arrange meeting (letter sent home).
7 July, 2017- meeting with Jason, his parents and form teacher. Concerns about weight loss,
fatigue and social withdrawal (Jason no longer appears to spend time with his friends). Jason
denies that he is underweight (wt today - 51kg) and claims that he ‘needs to lose a few kilos’.
Form teacher reports reduction in ability to concentrate and increased tiredness. Parents very
concerned – convinced Jason has anorexia nervosa.
WRITING TASK
Using the information in the case notes, write a letter of referral to Jason’s GP, Dr Paulson,
asking her for a medical review and diagnosis with a possible referral to an Eating Disorder
Clinic, if appropriate.
The doctor’s address is: Health Clinic, 47 Gilbert Rd, Broadway NSW
In your letter:
Expand the relevant case notes into complete sentences
Do not use note form
Write between 180 - 200 words
Use correct letter format
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