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Challenging · Referral · Nursing

A hand burn that won't heal, now infected

This case practises: A clear timeline · Making urgency clear · Including every key fact · Leaving out what the reader doesn't need

Writing task

Today's date: 4 December 2026. You are the nurse at Bayside Community Wound Clinic. Write a letter to Dr Sunita Rao, General Practitioner, Bayside Medical Practice, 45 Harbour Road, Bayside, Mr Haddad's GP, updating her on his wound and requesting an urgent review today. Write in full sentences, not note form, using letter format. Aim for a body of about 180–200 words.

Case notes

In the test you get 5 minutes to read, then 40 minutes to write.

Patient details
- Mr Karim Haddad, DOB 19/01/1970 (56 y.o.)
- 10 Pier Street, Bayside
- Referred by GP 30/09/2026 - burn R hand

Social background
- Works as a cook in a restaurant; off work since 25/09 (needs both hands)
- Married; wife works as a teacher
- Smokes 15 cigarettes/day; not ready to quit (02/10)
- Enjoys sea fishing; planning trip to Lebanon in summer 2027
- Son (19) at university in Leeds
- Supports Bayside FC; season ticket holder

Medical history
- Type 2 diabetes (2015) - metformin 1 g BD; gliclazide 40 mg OD added 10/2026; HbA1c 78 mmol/mol (09/2026)
- Hypercholesterolaemia - atorvastatin 20 mg nocte
- Knee arthroscopy 2018
- BMI 31
- Flu vaccine 10/2026
- Allergy: penicillin (anaphylaxis 2004)

Injury
- 25/09: hot oil splash, back of R hand - partial-thickness burn
- ED 25/09: cooled 20 min; tetanus booster given; dressing; discharged

Clinic visits (wound measured length x width)
- 02/10: 4.0 x 3.0 cm; clean; silver dressing; pain 3/10
- 16/10: 3.5 x 3.0 cm; some slough; BP 138/84
- 30/10: 3.0 x 2.5 cm; granulating; pt "keen to return to work"
- 06/11: did not attend (working extra shifts, he said later)
- 13/11: 3.0 x 2.5 cm - no progress; glucose 14.2 mmol/L in clinic; BP 142/88
- 27/11: 3.0 x 2.5 cm; edges rolled; told GP practice by phone - review of diabetes requested
- 04/12 (today):
  - Wound larger 3.5 x 3.0 cm; yellow-green discharge; malodour
  - Redness spreading 2 cm onto wrist; hand swollen
  - Pain 7/10; reduced finger movement (can't make a fist)
  - T 38.0 °C, HR 102
  - Wound swab sent today

Assessment
- ?wound infection with spreading cellulitis
- Non-healing at 10 weeks, likely contributing: smoking, poor diabetes control

Plan
- Urgent GP review today: antibiotics (NOTE penicillin anaphylaxis), consider hospital if worsening
- Request urgent referral to hand/plastic surgery team - non-healing burn affecting function
- Review of diabetes control (HbA1c 78; clinic glucose 14.2)
- Smoking cessation support - pt now willing (04/12)
- Wound clinic: twice-weekly dressings; next visit 08/12/2026

Write your letter

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Model answer Try writing your own letter first
Dr Sunita Rao
General Practitioner
Bayside Medical Practice
45 Harbour Road
Bayside

4 December 2026

Dear Dr Rao,

Re: Mr Karim Haddad, DOB 19/01/1970

I am writing to request an urgent review of Mr Haddad today, as the partial-thickness burn on the back of his right hand has failed to heal over ten weeks and now appears infected.

Following the hot-oil injury on 25 September, the wound gradually reduced from 4 x 3 cm to 3 x 2.5 cm, but it has not progressed since 13 November. Today it measures 3.5 x 3 cm, with yellow-green discharge and redness spreading 2 cm onto his wrist. His hand is swollen, he cannot make a fist, and his pain is 7/10. His temperature is 38.0°C and his heart rate 102. A wound swab was sent today.

I would be grateful if you could consider antibiotics, noting his penicillin anaphylaxis, and refer him urgently to the hand or plastic surgery team, as he works as a cook. His diabetes control also needs review, as his HbA1c is 78 mmol/mol and his clinic glucose was 14.2 mmol/L. He smokes 15 cigarettes a day but is now willing to quit.

We will continue twice-weekly dressings, with his next visit on 8 December.

Yours sincerely,

Wound Care Nurse
Bayside Community Wound Clinic

What the reader needs

  • Urgent review today
  • Partial-thickness hot-oil burn to the back of the right hand on 25 September
  • Healed slowly to 3 x 2.5 cm, then stopped improving from 13 November
  • Today: larger wound, discharge, spreading redness to the wrist, swelling, reduced finger movement
  • Temperature 38.0 °C and heart rate 102; wound swab sent
  • Penicillin anaphylaxis (relevant to antibiotic choice)
  • Requests: antibiotics, urgent hand/plastic surgery referral, diabetes review

Details to leave out

  • Wife's job
  • Fishing and the trip to Lebanon
  • Knee arthroscopy
  • Cholesterol and atorvastatin
  • Blood pressure on 16 October
  • Each visit's measurements listed one by one
  • Missed appointment reason
  • Son, football club
  • BMI and flu vaccine
  • Emergency department first aid and tetanus
  • Blood pressure readings

One good way to write this letter, not the only one. Written by Kurippu; awaiting nurse review.