Writing Test - Doctor

Time Allow ed - 40 minutes

Read the case notes below and complete the writing task which follows.

Patient'sname : Mrs. Lucy Clooney d.o.b. 18 April 1955

Social History : Bank manager, Heavy smoker ( 20 cigarettes daily for 30

years ), drinks alcohol occasionally

Past Medical History : Mild hypertension, Not taking medication regularly,

moderately overweight

18/8/2009
Subjective : discomfort in upper abdomen, burning sensation at the same
area since her early 20s, difficulty in swallowing solid foods. especially meat &
bread, Liquid- no problem, no nausea, no vomiting, not associated with
hoarseness of voice

Objective : pulse rate- 80/ min, BP- 135/85, no cervical lymph node swelling,
chest & abdomen- unremarkable, not clinically anaemic or jaundiced

Assessment : Dysphagia due to either hiatus hernia or other organic lesions

in oesophagus

Plan : explain the possible diagnosis, advise to stop smoking & to adjust her
life style, to consider further investigations for definitive diagnosis, review in 2
weeks

20/11/2009
Subjective : missed review visit, her symptoms- worsened, increasing
difficulty in swallowing, now regurgitated undigested solid foodstuffs but no
pain on swallowing, concerned about her weight loss ( 5 kg in 3 months ) ,
Antacid taken by self - not effective

Objective : examination - normal, rectal & abdominal - normal, no peripheral

oedema

Assessment : Hiatus hernia or mass in oesophagus

Plan : CXR, ECG, Endoscopy & Biopsy, refer to surgeon if abnormality found

25/11/2009
Subjective ; all symptoms- not improved, cough at night , sometimes being
woken from sleep, productive of clear sputum, not bile or blood stained, no
history of angina, shortness of breath, ankle swelling

Objective ; examination- still normal, no signs of maligancy, CXR- no

evidence of aspiration pneumonia, ECG- normal, Endoscopy- oesophagitis &
stricture at 36cm from incisor teeth showing small hiatus hernia, Biopsy -
consistent with oesophagitis & no malignancy identified

Assessment : Barette's oesophagus

Plan : lifestyle change ( smoking, drinking alcohol & stress ) , Gaviscon 30 ml

& Omeprazole 40 mg daily, repeat endoscopy at 6-8 weeks' time, to undergo
operation if malignancy is detected

23/1/2010
Subjective : now asymptomatic but continue to take regular omeprazole, She
wants to stop therapy , taking on board the lifestyle change , stopped
smoking, worried to take tablets for the rest of life

Objective : no abnormality found

Plan : refer to GI surgeon for assessment for operation ( fundoplication )

Writing Task

Using the information in the case notes, write a letter of referral to Dr. Harry
Smith at the Royal Melbourne Hospital, Flemington Road, Parkville 3050. In
your answer, expand the relevant case notes into complete sentences. Do not
use note form. The body of letter should be approximately 180-200 words.
Use correct letter format.