WRITING CORRECTION

Dr Penny Clinton
Department of Cardiothoracic Surgery
Central Hospital
Main Street
Stillwater

22/08/15

Dear Dr Clifton,
Re: Mrs Mary Clarke, D.O.B: 17/09/1960

I am writing to refer Mrs Clarke, a 54-year-old office clerk, whose features are suggestive of
bronchogenic carcinoma. Your further assessment and management including bronchoscopy and biopsy
would be highly appreciated.

Mrs Clarke has been smoking 30-35 cigarettes per day for more than 30 years. Her family history is
significant for laryngeal carcinoma and mining related lung disease related to her mother as well as father,
respectively.

Today, Mrs Clarke presented with the complaint of dry non-productive cough for 7 weeks which was
commenced with flu like symptoms and was associated with mild shortness of breath at night as well as
sensation of heaviness in chest. However, there was no history of hemoptysis or exercise intolerance. Her
physical examination was unremarkable except for signs of consolidation associated with monomorphic
wheeze in middle zone of the right lung. Her investigation reports revealed right middle lobe atelectasis
along with enlarged right hilum on chest x ray and CT scan. However, sputum cytology was normal.
Hence, she was counselled on possible diagnosis and the need for further investigations.

I believe Mrs Clarke has been suffering from bronchogenic carcinoma. I would be grateful if you could
further evaluate her including follow up investigations such as bronchoscopy and biopsy.

Should there be any queries, please do not hesitate to contact me.

Yours sincerely,
Doctor
Explanation:

1. Grammatical error was noticed.

2. Missed initial visit. Write initial visit after today’s visit as initial visit is less significant to today’s
visit

Word count 221

1. Purpose- Satisfactory
2. Content- Missed info
3. Conciseness and clarity- Minimum irrelevant information
Comment was written.
4. Genre and Style- letter was clinical formal and Non-
Judgmental. Preciseness hampered.
5. Organization and layout- Layout was maintained
6. Language- Grammatical error was noticed, appropriate
use of comma, Spelling, cohesion was good enough.
1. Follow the sample letter and explanation
part
2. Keep practicing
Advice

Estimated Grade B(360)

 A Sample letter of this case note

Dr Penny Clifton
Thoracic surgeon
Department of Cardiothoracic Surgery
Central hospital
Main Street
Stillwater

22.08.15

Dear Dr Clifton,
Re: Mrs Mary Clarke, DOB: 17-09-1960

I am writing to refer Mrs Clarke, a 54-year-old office clerk, whose features are suggestive of
bronchogenic carcinoma. Your further assessment and management including possible bronchoscopy
with biopsy would be highly appreciated.

Mrs Clarke is married and lives with her husband. She has been smoking 30-35cigarettes a day for more
than 30 years. Please note, her father and mother died of mining related lung disease and laryngeal
carcinoma respectively.

Today, Mrs Clarke visited with the complaints of a 7-week history of cough which was nonproductive in
nature associated with shortness of breath at night and feeling heaviness in her chest. Her exercise
capacity was fairly good. Her examination findings were unremarkable apart from signs of consolidation
along with monophonic wheeze in the mid-zone of the right lung. Besides, her sputum cytology was
normal. Consequently, her X-ray and CT scan of the chest revealed atelectasis in the right middle lobe
and an enlarged right hilum.

Initially on 04.07.15, Mrs Clarke presented with sore throat, body aches, fever and cough which were
treated with Augmentin.
My provisional diagnosis is bronchogenic carcinoma. I would be grateful if you could evaluate her and
arrange bronchoscopy with biopsy as you feel appropriate.

Should there be any queries, please do not hesitate to contact me.

Yours sincerely,
Doctor