WRITING CORRECTION

Dr F. Goldman
Paediatrician
171 Victoria St
Northfield

20/03/10

Dear Dr Goldman,
Re: Jamie Brown

I am writing to refer Jamie, a 5-year-old boy, who has been diagnosed with post-streptococcal
nephritis with early renal failure. Your further assessment and management would be highly
appreciated.

Initially on 25/02/10, Jamie presented with the complaints of sore throat, husky voice, fever and
irritability. On examination temperature was raised to 39° C, tonsils were enlarged as well as
infected with exudate. Additionally, cervical lymph nodes were enlarged and tender. Therefore,
Jamie was diagnosed with tonsillitis and penicillin V was prescribed.

2 days ago on 18/03/10, Jamie visited with history of brown urine 4 days ago. However, there was
no history of frequency, dysuria or trauma. On physical examination, tonsils were still hypertrophied
and macroscopic heamaturia was found. Therefore, Jamie was advised to drink plenty of fluids.
Suspecting post streptococcal nephritis or UTI, a set of investigations were ordered and a review visit
was planned in 2 days.

Upon today’s review, Jamie was hypertensive along with repeated macroscopic heamaturia. His
investigation reports revealed elevated levels of urea, creatinine and ASO titre. MSU M/C/S revealed
colony count of 4x10 and urine cell morphology showed RBC of renal origin. However, FBE was
normal.

Jamie has been diagnosed with post streptococcal nephritis with early renal failure. I would be
grateful if you could further evaluate him and treat his condition accordingly.

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

Yours sincerely,
Doctor
Explanation:

1. Grammatical error was noticed.

Word count 230

1. Purpose- Satisfactory
2. Content- Relevant info was written
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. Letter meets the criteria
2. Keep practicing

Advice

Estimated Grade B(360)

 A Sample letter of this case note

Dr. F. Goldman
Pediatrician
171 Victoria St.
Northfield

20/03/2010

Dear Dr. Goldman,

Re: Jamie Brown

Thank you for seeing Jamie, a 5-year-old boy, whose clinical features are consistent with post-
streptococcal nephritis with early renal failure. Your further assessment would be highly appreciated.

Initially on 25/02/2010, Jamie visited my clinic and was diagnosed with tonsillitis. Therefore, he was
treated with penicillin. Three weeks later, his mother observed that he was tired and lethargic in
addition to passing brown colored urine four days back. Hence, some blood and urine tests were
ordered along with advice to maintain fluid intake.

On review today, Jamie has still no symptoms. On examination, an elevation of blood pressure was
noted. Besides, his investigations revealed elevated levels of urea, creatinine, ASOT and presence of
RBC of renal origin on MSU.

Jamie requires your assistance regarding the management of his post-streptococcal nephritis with
early renal failure.

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

Yours sincerely,
Doctor
Case Note