Discharge letter – chest pain and GERD

*Case note is blurry, but most information are irrelevant, so just refer to the details

written down

Paragraph one – patient, condition, request

Mrs Henning was presented to the Emergency Department today after experiencing chest

pain that might be attributable to gastro-esophageal reflux. Your follow up care is highly
appreciated.

Paragraph two

Details: 6/01/2016 – new onset of chest pain 2-3 episodes, “compression” pain only at

night, improved with repositioning (use 2 pillows), recently consuming larger meals at night

Mrs Henning presented with 2-3 bouts of chest pain. She also complained that she felt

“compression” pain on her chest at night, which was relieved by repositioning herself

using two pillows. In addition, she mentioned that she has been eating larger meals at

night recently.

Mrs Henning presented with 2-3 bouts of chest pain. She complained of compression-like

chest pain at night, which can only be alleviated by elevating herself with the help of two

pillows. She also reported that she has been consuming larger meals at night recently.

Paragraph three

Details: generally thin, vitals such as BP, heart sounds, abdomen sounds are normal
An assessment noted that Mrs Henning is thin. However, her Vitals such as BP, heart sounds,

abdomen sounds are normal

Or we can simply put this information in paragraph 2 saying that: Mrs Henning’s physical

examination was unremarkable

Paragraph four

Details: provisional diagnosis – chest pain resulting from GERD as only when lying down /

not presented with exertion / larger meals at night

Update patient’s GP of recent onset

COPD – continue medications. Follow up with GP in 3-4 weeks.

Chest pain – discontinue eating 2-3 hours prior to sleep, follow up with GP in 3-4 weeks –

if chest pain continues despite meal adjustment – call GP or visit emergency department.

If chest pain begins on trigger – call GP or visit emergency department

My provisional diagnosis of Mrs Henning is chest pain attributable to GERD because her

pain is only present when she is lying down or after she has consumed larger meals at

night. As you are aware that Mrs Henning has COPD, it is recommended for her to continue
with her current medications – albuterol inhalers. Regarding Mrs Henning’s chest pain, it

is advisable for her to stop eating 2-3 hours before sleeping. However, if this chest pain

persists or is triggered by exertion, she should consult you or visit the emergency

department immediately.

Mrs Henning’s condition is an indicative of chest pain attributable to GERD because her

pain is only present either when she is lying down or after eating larger meals at night. The

fact that pain doesn’t occur during exertion supports the finding. Since Mrs Henning has

COPD, it is recommended for her to adhere to her current medications. Regarding Mrs

Henning’s chest pain, it is advisable for her to avoid eating 2-3 hours before sleeping.

However, if this chest pain persists or if it is triggered by exertion, she should report it to

either yourself or to the emergency department at once.

Discharge letter - Falls
Paragraph: patient / condition / request
Mrs Anne Jenkis (*patient) was brought into our emergency department today by an
ambulance due to a fall (*condition) at home this morning. We have some concerns about
her general level of self-care and would like you to follow up. (*request)

Paragraph one

Details: fell at home this morning, no injury found, neighbor came to her assistance
and called the ambulance, disheveled, unable to get up from the ground by herself,
seemed confused, unable to contact her children so left message on daughter’s message
bank, neighbor claimed that she had a few recent falls which needed assistance,

Mrs Jenkis fell at home this morning but we couldn’t find any specific injuries. Her
neighbor came to her assistance and called the ambulance. When her neighbor found her,
she was disheveled and was unable to get up from the ground by herself. Her neighbor
also reported that she had a few recent falls requiring assistance. Although she was
aware about her surroundings and people, she seemed to be confused about the date and
time. (*She also seemed to be suffering from some memory loss) We were unable to contact
Mrs Jenkis’s children, so I sent a message to her daughter’s message bank.

Paragraph three

Details:
 hypertensive, atrial fibrillation, rhonchi heard in lungs, chest x-ray: cardiomegaly
 leukocytes in urine ward
 no clinical fractures noted hips lower limbs, hips full range of motion, no
shortening / abnormal rotation of legs, osteoporosis, ambulates without pain
 healing grazes and bruise elbows,

According to our assessment, we noted that Mrs Jenkin’s had some healing grazes and
bruises on her elbows due to her previous falls. X-rays of her hips and legs were normal
and she was able to ambulate without any pain. However, she was hypertensive, had atrial
fibrillation and cardiomegaly (borderline), and some leukocytes were found in her urine
ward.

Paragraph four - request

Details: Discharge plan – letter to GP to follow up: TFTs, digoxin test, MSU, Geri rv,
home help / placement

Could you please follow up and act on her TFTs, digoxin levels and MSU results? In
addition, would you consider her for a geriatric review? Finally, she may require home
help or placement into care. Should you have any questions, please do not hesitate to
contact me.
Referral letter – obesity

Notes
Model letter sample 1

Model letter sample 2

Dr D Kurac (name of doctor you are referring the patient to)

Surgeon

Weight center (address)

393 Victorian Road

Richmond, Melbourne

15 June 2018 (Date – format doesn’t matter)

Dear Dr Kurac (Dear name of doctor.)

Re: Andy Williams, aged 65 years old (Re: patient and age / DOB. If age and DOB are both

given, write DOB instead)

Paragraph one: Patient / Condition / Purpose – formats are more or less fixed for all

referral letters

Patient – Andy Williams. Condition – obesity. Purpose - Evaulation of obesity and

recommendation for treatment (but in paragraph 1, lets keep it brief – evaluation and

treatment. We will save the details - Evaulation of obesity, recommendation for treatment

for the last paragraph aka request)

 I am referring Andy Williams (*Patient), who has been suffering from obesity

(*Condition), to you for evaluation and treatment (*Purpose)

 I am writing to refer Andy Williams (*Patient) to you. He has been suffering from

obesity (*Condition). Your evaluation and treatment (*Purpose) would be highly

appreciative.

 Thankyou for seeing Andy Williams (*Patient), who has been suffering from obesity

(*Condition). for evaluation and treatment (*Purpose)

Paragraph 2

Details: 163 cm, 155.5 kg, BMI 46.6, family history of obesity, medical history (type 2

diabetes, hypertension, sleep apnea, BG levels 100-130 mg/dl, triglycerides 201 mg/dl,

serum insulin insulin 19 IU/ml). Medications (30 and 70 units of NPH insulin before

breakfast / before or after dinner, 850 mg metformin twice daily, atorvastatin, lisinopril

and nifedipine)

Mr Williams has a family history of obesity. He weighs 155.5 kg and his BMI is around

46.6 kg/m2. He presents with diabetes, hypertension and sleep apnea. Lab reports

showed (revealed) that his blood glucose was within 100-130 mg/dl and serum insulin

and triglycerides were 19 IU/ml and 201 mg/dl respectively. His medications included 30

and 70 units of NPH insulin before breakfast / before or after dinner, 850 mg metformin

twice daily, atorvastatin, lisinopril and nifedipine.

Paragraph 3

Details: Childhood obesity, gains weight every decade, at highest adult weight,

participated in commercial and medical weight loss programs, consulted registered

dietician,

Mr Williams has been suffering from obesity since he was a child. He participated in

various weight loss programs and even consulted a dietician. However, these failed to

tackle his obesity problem (failed to reduce his weight to an acceptable range)

*Alternatively, it might be better to combine: family history of obesity, weighs 155.5 kg,

childhood obesity together into one paragraph and diabetes / hypertension, lab reports,

medications into one paragraph

Paragraph 2

Mr Williams has a family history of obesity. He has been suffering from obesity since

childhood. Despite participating in various weight loss programs and consulting a

dietician, he continues to put on weight and currently weighs 155.5 kg with a BMI of 46.6

kg / m2.
Paragraph 3

Mr Williams presents with diabetes, hypertension and sleep apnea, for which he is taking

30 and 70 units of NPH insulin before breakfast / before or after dinner, 850 mg

metformin twice daily, atorvastatin, lisinopril and nifedipine. Lab reports showed that his

blood glucose fell within 100-130 mg/dl and serum insulin and triglycerides were 19

IU/ml and 201 mg/dl respectively.

Paragraph 4 Details: Diet - 3 meals / day. Reports limited fast food consumption 2 nights

/ weeks, no alcohol, reports binge eating triggered by stress，plan - Concerned about

health / wants to get life under control, wants to learn about surgical options, partner

encouraging.

Mr Williams eats 3 regular meals per day. He limits fast food consumption and doesn’t

drink any alcohol. However, he claims (reports / said that) to binge eat occasionally due

to stress. He has the support of his partner and is considering surgical treatments that

may help him get his weight and general health under control.

Paragraoh 5 - Request: more or less the same format for all referall lettes - In the view
of above, kindly evaluate ……

Details - Evaulation of obesity, recommendation for treatment

In the view of above, kindly evaluate Mr William’s condition and suggest him the most

appropriate treatment regime. Should you have any questions, please do not hesitate to

contact me.
Referral letter – Allergies

Notes
Model letter

Dr Ian Robson
Allergist
Central Hospital Oldtown

17/06/18

Dear Dr Robson

Re: Mr Tom Riddle (DOB: 19/05/08)

Paragraph one

I am referring Mr Riddle, who is presenting with asthmatic symptoms, to you for further
testing and identification of his allergies.

Paragraph 2

Details: family history of asthma, childhood asthma – nil episodes 8 years, eczema
(periodic), no known allergies

Mr Riddle has a family history of asthma. He was diagnosed with childhood asthma, which
was well controlled for the past 8 years (which didn’t show any symptoms for the past
8 years). He has eczema but no known allergies.

Paragraph 3:

Details:

1/6/18 - 2 weeks breathlessness “needs to sit up”, persistent coughing / wheezing,

eyes itching, missing classes. Notes: new accommodation – two cats, dusty old carpet,
sleeps on floor

2/6/18 – CXR clear, Pre-bronchodilator – FEV1: 3.61, Post-bronchodilator – FEV1:

4.35, response positive – 20%. Diagnosis: asthma, Plan: oral prednisolone 50 mg – 10
days, albuterol inhaler,

Mr Riddle presented at my clinic on 1/6/18. He complained about breathlessness for 2

weeks, persistent coughing and itchy eyes, which resulted in his absence from college.
He also mentioned that he moved into a new accommodation where he had two cats, a dusty
old carpet and slept on the floor. In the subsequent visit on 2/6/18 (*Too long winded,
we can simply use “1 month later”), Mr Riddle’s Pre-bronchodilator – FEV1: 3.61,
Post-bronchodilator – FEV1: 4.35, and response positive – 20% indicated that he had
asthma (showed that he was diagnosed with asthma), and for that, I administered him
with oral prednisolone (*omit 50 mg – 10 days. Such details aren’t necessary) and
albuterol inhaler.

*?? Perhaps it might be alright if I made the following alterations: 1 month later, Mr
Riddle’s Pre-bronchodilator and post-bronchodilator values and response positive
percentage indicated an asthma episode, which was treated with oral prednisolone and
albuterol inhaler.

Paragraph 4

Details: 14/6/18 - sleep disruption, albuterol increased, eczema flare, vitals (BP,
pulse, respiratory rate) above normal levels, Oxygen saturation and PaO2 below normal
level. Auscultation – bilaterally diminished lung sounds, expiratory wheezing,
administered oxygen 3L, attained O2 sat 93%, albuterol hourly, IV corticosteroid –
positive response. 17/8/18 – discussed environmental triggers, proper inhaler technique
On 14/6/18, he presented with sleep difficulties and eczema. His blood pressure, pulse
respiratory rate were above normal levels, whereas, his oxygen saturation and PaO2 were
below normal levels. Auscultations revealed diminished lung sounds and expiratory
wheezing. 3L of oxygen, albuterol (hourly) and IV corticosteroid were administered. 2
months later, I educated him about environmental triggers and proper inhaler technique.

*Alternatively, we can omit details such as: “His vitals such as: blood pressure, pulse
respiratory rate were above normal levels, whereas, his oxygen saturation and PaO2 were
below normal levels.” Because 3 L of oxygen, albuterol and IV corticosteroid managed
to deal with them.

Modified answer: on 14/6/18, he presented with sleep difficulties and eczema. His vitals
such as blood pressure, oxygen saturation, were not within normal levels. Diminished
lung sounds and expiratory wheezing were heard during auscultation. Oxygen, hourly
albuterol and IV corticosteroid were administered. On subsequent visits, I educated him
on environmental triggers and proper inhaler technique.

So: Model answer: Twelve days later, he presented again with an acute exacerbation of
bronchial asthma that was treated with oxygen, hourly albuterol and intravenous
corticosteroids. Subsequent to this visit, he was educated about possible environmental
triggers and proper inhaler technique.

Paragraph 5:

Details: further testing and identification of his allergies, provide guidance on

environmental management.

In view of the above, kindly conduct the necessary allergenic tests and provide guidance
on environmental management. Should you have any questions, please do not hesitate to
contact me.
Referral letter – arrhythmia (heart flutter)

Read the cases notes below and complete the writing task which
follows:

Time allowed: 40 minutes

Today's Date

08.08.09

Patient History
Dulcie Wood

DOB 15.07.43

New patient in your General Practice. Moved recently to be near

family.

03.07. 09
Subjective
Widowed January 06, three children, wants regular check up, has
noticed uncomfortable feeling in her chest several times in the last
few weeks like a heart flutter.
Mother died at 52 of acute myocardial infarction, non smoker, rarely
drinks alcohol
Current medication: zocor 20mg daily, calcium caltrate 1 daily
No known allegeries

Objective
BP 145/75 P 80 regular
Ht 160cm Wt 61kg
Cardiovascular and respiratory examination normal ECG normal

Plan
Prescribe Noten 50 gm ½ tablet daily in am. Advise to keep record
of frequency of fibrillation sensation.
Review in 2 weeks if no increase in frequency.

17.07.09
Subjective
Reports sensations less but woke up twice at night during last 2
weeks

Objective
BP 135/75 P70 regular
Assessment
Increase Noten to 50 gm daily ½ tablet am and ½ tablet pm
Advise review in one month.

08.08.09
Subjective
Initial improvement but in last 3 days heart seems to be fluttery
several times a day and also at night. Very nervous and upset.
Wants a referral to a cardiologist Dr.Vincent Raymond who treated
her sister for same condition

Objective
BP 180/90 P70

Action
Contact Dr Raymond’s receptionist and you are able to arrange an
appointment for Mrs Wood at 8am on 14/08/09

Writing Task

Write a letter addressed to Dr. Vincent Raymond, 422 Wickham Tce,

Brisbane 4001 describing the situation.

In your answer:

 Expand the relevant case notes into complete sentences

 Do not use note form
 The body of the letter should not be more than 200 words
 Use correct letter format

Last modified: Tuesday, 12 January 2010, 05:16 PM

Sample Model Letter 3

08/08/09
Dr Vincent Raymond
422 Wickham Tce
Brisbane, 4001

Dear Dr Raymond,
Re: Dulcie Wood
DOB: 15/07/43

As arranged with your receptionist, I am referring this patient a 66

year old widow, who has been demonstrating symptoms suggestive
of heart arrhythmia.
Mrs. Woods has seen me on several occasions in the past five
months, during which time she has had frequent episodes of heart
flutter and her blood pressure has been fluctuating.

The patient initially responded to Noten 50mg ½ tablet daily in the

morning, but she still had episodes of disturbed sleep during the
night. Therefore the dose of Noten was increased to 50mg ½ tablet
in the morning and ½ tablet at night, but unfortunately her heart
flutter has increased recently, especially over the last three days.
Other current medications are Zocor 20mg and Calcium Caltrate 1
daily.

Today’s examination revealed a nervous and upset woman with a

pulse rate of 70 and blood pressure of 180/90.

Please note that her mother died of acute myocardial infarction and
her sister, who is a patient of yours, has a similar condition.

In view of the above, I would appreciate it if you provide an

assessment of Mrs. Wood and advise regarding treatment and
management of her condition.

Yours sincerely,

Dr Z

Word Length: 191 words

Last modified: Friday, 20 August 2010, 11:26 AM

Referral letter - asthma

Notes
Model letter sample 1

Model letter sample 2

Dr Jan Walker
Pulmonologist
Epstein Clinic
393 Victorian Road
Richmond, Melbourne

2 September 2017

Dear Dr Walker

Re: Susan Forrest (DOB: 19/05/1997) - (Re: patient and age / DOB. If age and DOB are
both given, write DOB instead)

Paragraph one: Patient / Condition / Purpose – formats are more or less fixed for all
referral letters

I am referring Susan Forrest (*Patient), who has been suffering from asthma (*Condition),
to you for assessment and treatment evaluation (*Purpose)

Paragraph 2

Details:

Smoker – 7 years, 10-15/day

Father also has asthma
Asthma since age 4
Two previous asthma related hospital admissions, most recent 2015
Allergic rhinitis, eczema
Smoking cessation options discussed

Susan Forrest has a family history of asthma and has been suffering from asthma since
4 years old. In addition, she experienced two asthma exacerbations (most recent in 2015)
which caused her to become hospitalized. She also presents with allergic rhinitis and
eczema. On top of that, she has been smoking around 10-15 cigarettes every day for the
past 7 years.

Paragraph 3

Details: Current drugs: Ventolin (albuterol), symbicort (budesonide/formoterol) –

twice daily, Zyrtec (cetirizine). Non-compliance with preventive inhaler – “forgets”
Currently, she is administered with Ventolin (albuterol), symbicort
(budesonide/formoterol) and Zyrtec (cetirizine). She also mentions that she tends to
forget to bring her preventive inhaler with her.

*Actually, we don’t have to include that much details on drugs. Simply: Currently, she
is administered with Ventolin (albuterol), symbicort and Zyrtec……

Paragraph 4

Details:

25/8/17, short of breath – ongoing, nocturnal cough 7 nights, Ventolin use increase
2/9/17 – pulse, temperature, BP within normal limits; CXR clear; FBE clear; PEF 400
L/min

She presented (came to) at my clinic on 25/8/17 complaining about an ongoing shortness
of breath, persistent night coughs, and the need to increase Ventolin usage. During her
next visit on 2/9/17 (*This is too long winded, use “one week later” instead since
25/8/17 to 2/9/17 is around one week). Her pulse, temperature and blood pressure are
all within normal limits, her chest X-ray is clear and her PEF is 400 L/min.

Paragraph 5

Details: assess and evaluate, ? continue with current meds

*Notice that the assessment and evaluation here are pretty brief. It didn’t specify
assessment of what? Evaluation of what? Here we can add more details based on our
understanding of the case notes.

In the view of above, kindly conduct a thorough (comprehensive) assessment on Susan

Forrest’s respiratory condition and a detailed evaluation on the suitability of her
current medications (detailed evaluation if it is advisable for her to continue with
her current medications). Should you have any questions, please do not hesitate to
contact me.
Referral letter – bowel cancer

Read the cases notes below and complete the writing task that
follows

Time allowed: 40 minutes

Today's Date

03.07.09

Patient History
Margaret Leon 01 .08. 49

Gender: Female

Regular patient in your General Practice .

14.01.09
Subjective
Wants general check up, single, lives with and takes care of elderly
mother.
Father died bowel cancer aged 50.
Had colonoscopy 3 years ago. Clear
Does not smoke or drink

Objective
BP 160/90 PR 70 regular
Ht 152cm
Wt 69 kg
On no medication.
No known allergies.

Assessment
Overweight. Advised on exercise & weight reduction.
Borderline hypertension.
Review in 3 months

25.04.09
Subjective
Feeling better in part due to weight loss

Objective
BP 140/85
PR 70 regular
Ht 152cm
Wt 61 kg
Assessment
Making good progress with weight. Blood pressure within normal
range

03.07.09
Subjective
Saw blood in the toilet bowl on two occasions after bowel motions.
Depressed and very anxious. Believes she has bowel cancer.
Trouble sleeping.

Objective
BP 180/95 P 88 regular
Ht 152cm Wt 50 kg
Cardiovascular and respiratory examination normal.
Rectal examination shows no obvious abnormalities.

Assessment
Need to investigate for bowel cancer
Refer to gastroenterologist for assessment /colonoscopy.
Prescribe 15 gram Alepam 1 tablet before bed.
Advise patient this is temporary measure to ease current
anxiety/sleeplessness.
Review after BP appointment with gastroenterologist

Writing Task

Write a letter addressed to Dr. William Carlson, 1st Floor, Ballow

Chambers, 56 Wickham Terrace, Brisbane, 4001 requesting his
opinion.

In your answer:

 Expand the relevant case notes into complete sentences

 Do not use note form
 The body of the letter should not be more than 200 words
 Use correct letter format

Last modified: Tuesday, 12 January 2010, 09:08 AM

03/07/2009

Dr. William Carlson

First Floor,
Ballow Chamber
56 Wickham Tce,
Brisbane 4001

Dear Doctor Carlson,

Re: Margaret Leon

DOB 01/08/1949

Thank you for seeing my patient, Margaret Leon, who has been very
concerned about blood in her stools. She has seen blood in the
toilet bowl on two occasions after bowel motion. She is very anxious
and as well as that depressed because her father died of bowel
cancer and she feels she may have the same condition.

Margaret has otherwise been quite healthy. She does not drink or
smoke and is not taking any medication. She was slightly
overweight six months ago with borderline high blood pressure. At
that time I advised her to lose weight which she did successfully.
Three months later, her weight had dropped from 69kg to 61kg and
blood pressure was back within normal range.

On presentation today she was distressed because she believes she

has bowel cancer. She has had trouble sleeping and her weight has
reduced a further 11 kg. The rectal examination did not show any
abnormalities. Her blood pressure was slightly elevated at 180/95
but her cardiovascular and respiratory examination was
unremarkable. Alepam, one before bed, was prescribed to control
the anxiety and sleeplessness.

I would appreciate it if you could perform a gastroenterology

assessment.

Yours sincerely,

Dr X (GP)
Referral letter – fibroids
Model letter

Paragraph one: patient / condition / request

Patient – Mrs Fielding. Condition – fibroids, request – further investigation and

diagnosis

I am writing to refer Mrs Fielding, who is presenting with symptoms suggestive of

fibroids, to you for further investigation and diagnosis.

Paragraph two

Details

3/1/19 – very tired, pale, heavy periods for 9 months, passing large clots, change
pads and tampons frequently, appetite unchanged

Mrs Fielding first presented to my clinic with her husband on 3/1/19. She appeared pale
and fatigue. She complained about heavy periods (menorrhagia suspected) for 9 months,
which required her to change pads and tampons very frequently, even during the night.
In addition, she observed large blood clots during her periods.
Paragraph three

Details: systemic examination, thyroid, vaginal inspection were unremarkable, speculum:

cervix orifice closed, no oozing of blood via orifice, pelvic examination: bulky uterus,
no adnexal tenderness or masses

Systemic examination was unremarkable and thyroid tests and vaginal inspection were
normal. However, a Pelvic examination found that she has an enlarged uterus.

Paragraph four

Details: provisional diagnosis – fibroids, ordered blood tests: FBC, TFT, coagulation
(send to gynecologist once received), pap smear (> 2 years since previous test),
transvaginal examination, iron supplement – floradix before meals, stop aspirin intake
/ change to panadol for pain relief

My provisional diagnosis of Mrs Fielding is fibroids. I have ordered the following blood
tests: FBC, TFT and coagulation, for which I instructed Mrs Fielding to forward them to
you upon receiving. Mrs Fielding is deal for a pap smear as her last test was more than
2 years ago. I also ordered a transvaginal examination to help identify the cause of
her unexplained bleeding.

I prescribed Mrs Fielding with floradix and advised her to stop taking aspirin and
consume Panadol instead should she experiences pain.

In the view of above, kindly conduct the necessary investigations to confirm my

provisional diagnosis. Should you have any questions, please do not hesitate to contact
me,
Referral letter – Gastro-esophageal reflux
Model letter

For case notes like this – with one provisional diagnosis at the very end, we can write
the letter this way

Paragraph one

I am writing to refer Ms Hall, who is presenting with symptoms suggestive of Gastro-

esophageal reflux, to you for further investigation and diagnosis.

Paragraph two:

Details: father – peptic ulcer, 2004 dyspepsia, 2006 dermatitis; Rx oral and topical
corticosteroids

Ms Hall has a history of peptic ulcer. She was diagnosed with dyspepsia in 2004 and
dermatitis in 2006, for which she was prescribed oral and topical corticosteroids.
Paragraph three

Details: 18/6/10 – dysphagia (solids), no relapse / remittent course, no sensation of

lump, concomitant epigastric pain radiating to back level T12, weight loss: 1-2 kg

Ms Hall presented to my clinic on 18/6/10 with dysphagia of solids which followed a

remittent course but didn’t feel any lump in her throat or stomach during swallowing.
In addition, she complained about a concomitant epigastric pain which radiated to her
back, specifically, at T12. She also experienced weight loss of around 1-2 kg.

Paragraph four

Details: URTI self -mediated with OTC Chinese herbal product – contents unknown, recent
increase in coffee consumption, takes aspirin occasionally (2-3 times / month)

Ms Hall self- prescribed an over-the-counter Chinese herbal product with unknown

ingredients for her upper respiratory tract infection. She also reported to increase
coffee consumption recently. (Recently, she has increased her coffee consumption)
Furthermore, she takes aspirin 2-3 times per month.

Paragraph five

Details: non-smoker (since children born), social drinker (mainly sprints), BMI 28.2

Please also note that Ms Hall has stopped smoking for many years, is a social drinker
(mainly sprints), and has a BMI of around 28.2.

Paragraph six

Details: further investigation and definitive diagnosis

In the view of above, I am concerned that Ms Hall’s condition will worsen, and it would
be highly appreciated if you can conduct further investigations and necessary
managements, to confirm my provisional diagnosis (indicate definitive diagnosis)

Or simply

In the view of above, kindly evaluate Ms hall’s condition and conduct the necessary
investigations to confirm my provisional diagnosis.
Referral letter – memory loss

Notes

Your long-term patient, Mrs Walshman, has attended your GP surgery with her daughter.
Both are concerned about Mrs Walshman’s memory.

Patient: Mrs Patricia Walshman (D.O,B: 10/07/1933)

Address: 24 Kenneth St, Newtown
Marital status: widowed, 5 adult children
Next of kin: Christine – daughter
Diagnosis: osteoporosis. Dementia (? Early stage Alzheimers)
Social background: widowed 40 yrs, lives alone, children within 10 km radius
Medications: osteo vit-D 1000 IU, atorvastatin (lipitor) 20 mg mane, ibuprofen (Bruten)
200 mg prn, metoprolol 100 mg b.d, paracetamol (panadol 500 mg) prn

Past medical history

2010 – 2016 Regular GP visits to this clinic, pathology, BP – stable

1 October 2017 Fall – bruised nose only, X-ray – NAD, will begin to take it easy,
slow down
8 November 2017
 Occupational therapist (OT) home assessment. Evaluated shower rails, ramp, bed ok.
R/V 4-6 months
 Discussed shower with OT. All ok
 Shower every other day to lessen likelihood of falls
 Community support: home care provided by local council. 1 / fortnight

26 March 2018
 BP 145 / 85
 FBE: U&E, LFTs – all NAD
 Total cholesterol 4.8 mmol/l (<5.5)
 HDL cholesterol 1.4 mmol/l (0.9-2.2)
 *LDL cholesterol 2.9 mmol/l (<2.0)
 Triglycerides 1.1 mmol/l (0.5-2.0)
 LDL/HDL 2:1
 Chol/HDL 3:4
 *Vitamin D < 54 (60-160 mmol/l)

Discussions:
 spare scripts – not filling them or not taking medication regularly
 Assures me she is taking medication regularly
 Suggested Webster pack (a sealed weekly calender pack designed to help people take
their medication correctly), was reluctant, promised to adhere to medication regime
 Review 2 months, post-pathology
1 August 2018

 BP 130/70, vit and lipids within normal range

 Medication issue resolved
 Daughter with pt, both want to discuss memory issues
 Poor memory noted ++ e.g. forgetting hairdresser appointments, dinner engagements,
missing social events. Behavioral changes, decision making issues

Mini memory assessment:

 Poor short-term memory, day & date – several attempts, no results. Month – 3
attempts. Confirmed the year correctly. Quite worried
 Requested further assessment
 Family history of Alzheier’s
 Asked about dementia – explained difference between Alzheimer’s disease and
dementia
 More assessments before diagnosis. Referred  Memory clinic
 R/V post-assessment

Writing task – using the information given in the case notes, write a letter of
referral to Dr Jones at the Newtown memory clinic, 400 Rail rd, Newtown, to provide him
with your brief assessment and request full memory assessment and diagnosis.
Model letter

Dr Jones (name of doctor you are referring the patient to)

Newtown Memory clinic (address)
400 Rail Rd
Newtown

1 August 2018 (Date – format doesn’t matter)

Dear Dr Jones (Dear name of doctor.)

Re: Mrs Patricia Welshman (DOB: 10/07/1933) – (Re: patient and age / DOB. If age and
DOB are both given, write DOB instead)
Paragraph 1: patient, condition, purpose. Format is more or less the same

Patient – Mrs Welshman. Condition – memory issues. Purpose – full memory assessment
and final diagnosis

I am referring Mrs Welshman, a long-term patient of mine, who is presenting with memory
issues, to you for full memory assessment and final diagnosis.

Paragraph 2:

Details:

1 August 2018

 Daughter with pt, both want to discuss memory issues

 Poor memory noted ++ e.g. forgetting hairdresser appointments, dinner engagements,
missing social events. Behavioral changes, decision making issues

Mini memory assessment:

 Poor short-term memory, day & date – several attempts, no results. Month – 3
attempts. Confirmed the year correctly. Quite worried
 Requested further assessment
 Family history of Alzheimer’s
 Asked about dementia – explained difference between Alzheimer’s disease and
dementia
 More assessments before diagnosis. Referred  Memory clinic
 R/V post-assessment

Mrs Welshman and her daughter came to my clinic on 1 August 2018 to discuss about Mrs
Welshman’s failing memory issues, which were evident in examples such as: forgetting
appointments and engagements. In addition, Mrs Welshman demonstrated behavioral changes
and experienced decision- making difficulties. I conducted a mini memory assessment and
found out that Mrs Welshman was suffering from poor short-term memory as she was unable
to remember the day and date of recent events. Mrs Welshman has a family history of
Alzheimer. However, more assessments need to be conducted prior to confirming the
diagnosis.

Model paragraph

Mrs Welshman and her daughter presented at my clinic to discuss the deteriorating state
of her memory. They cited several examples of forgetfulness including missing
appointments and perceived changes in her behavior and decision making. Upon conducting
a mini memory assessment, the patient’s short term memory was found to be poor and she
was unable to recall the day and date. Given that there is a family history of
Alzheimer’s disease, Mrs Welshman and her family are clearly anxious and have asked
for a more extensive evaluation.
Paragraph 3

Details

 Hyperlipidemia and Vit D deficiency

 spare scripts – not filling them or not taking medication regularly
 Assures me she is taking medication regularly
 Suggested Webster pack (a sealed weekly calender pack designed to help people take
their medication correctly), was reluctant, promised to adhere to medication regime
 Review 2 months, post-pathology

In terms of past medical history, Mrs Welshman failed to take her medications for
hyperlipidemia and Vitamin D deficiency regularly. Moreover, she had not been filling
up spare scripts. Therefore, a Webster pack had to be implemented to help her better
manage her medications.

Paragraph 4

Details - request full memory assessment and diagnosis.

*Notice that full memory assessment is detailed enough because it specifies what kind
of assessment that should be conducted. However, diagnosis is pretty brief here. Here,
we can add other details based on our own understanding of the case notes.

In the view of above, kindly conduct a full memory assessment and other appropriate
follow up on Mrs Welshman to confirm the provisional diagnosis. I have arranged Mrs
Welshman for another appointment after your assessment. Should you have any questions,
please do not hesitate to contact me.

In the view of above, kindly conduct a full memory assessment and other appropriate
follow up on Mrs Welshman prior to reaching a final diagnosis (so that a final diagnosis
can be made /so as to come up with a final diagnosis). I have arranged Mrs Welshman for
another appointment after your assessment. Should you have any questions, please do not
hesitate to contact me.
Referral letter - meningitis

Time allowed: 40 minutes

Read the case notes below and complete the writing task that follows:

Today’s Date
14.10.10

Patient History

Amina Ahmed aged 8 years – new patient at your clinic Parents – Mother Ayama,
house-wife. Father Talan, cab driver Brothers Dalma aged 4 and Roble aged 2
Family refugees from Somali 2005. Have Australian Citizenship Amina and father
good understanding of English, mother has basic understanding of slowly spoken
English. Amina had appendicectomy 2 years ago
No known allergies

09/10/10

Subjective

Fever, runny nose, mild cough, loss of appetite

Unable to attend school

Objective

Pulse 85/min
Temperature 39.4
No rash
No neck stiffness
CVS, RS & abdo – normal

Assessment

Viral infection

Management

Keep home from school

Rest and paracetamol three times daily
Review in 3 days if no improvement

12/10/10

Subjective

Amina not well

Cough +, continuous headache, lethargic, loss of appetite
Difficult to control temperature with Paracetamol
Mother worried

Objective

Fever 39.8 C
No rash or neck stiffness
Management

Prescribe Brufen 200mg as required

FBC & UFR were ordered
Review in two days with results of reports

14/10/10

Subjective

Both parents very concerned

Reported Amina lethargic and listless
Vomited twice last night and headaches worse

Objective

FBC- WBC(18000) and left shift

Urinary Function Report Normal
Temperature 40.2C
Pulse 110/min
Macula-papular rash over legs
Neck Stiffness+

Assessment

Meningococcal Meningitis Penicillin IV given (stat dose)

Plan

Arrange urgent admission to the Emergency Paediatric Unit,

Brisbane General Hospital, for further investigation and treatment.

Writing Task
You are GP, Dr Lucy Irving, Kelvin Grove Medical Centre, 53 Goma Rd, Kelvin
Grove, Brisbane. Write a referral letter to the Duty Registrar, Emergency
Paediatric Unit, Brisbane General Hospital, 140 Grange Road, Kelvin Grove, QLD,
4222.

In your letter:

 Expand the relevant case notes into complete sentences.

 Do not use note form.
 The body of your letter should be approximately 200 words.
 Use correct letter format.

Kevin Grove Medical Centre

53 Goma Road
Kelvin Grove, Brisbane
14.10.09

The Duty Registrar

Emergency Paediatric Unit
Brisbane General Hospital
140 Grange Road
Kelvin Grove, QLD, 4222

Dear Doctor:
Re. Amina Ahmed (8years)

I am writing to refer Amina who is presenting with signs and

symptoms of meningococcal meningitis for urgent assessment and
management. She is the first child of a family of 5, which includes
her parents and two younger siblings. They are immigrants from
Somalia, though she and her father understand English.

Initially, accompanied by her parents, she presented to me on

9.10.10 with complaints of fever, runny nose, cough and loss of
appetite. She was febrile with a temperature of 39.4 and a pulse
rate of 85 beats per minute, but there was no rash or neck
stiffness. However, her condition continued to deteriorate over the
next two days as the fever could not be controlled by antipyretics.
Therefore, blood and urine tests were ordered.

Regrettably, today Amina became lethargic and listless. She

vomited twice last night and had been having severe headaches. On
examination, she was severely febrile with a temperature of 40.2
and a pulse rate of 110 beats per minute. There was macula-
papular rash over the legs and neck stiffness was present. Blood
test showed leucocytosis with a shift to the left.

Based on the above, I believe she needs urgent admission and

management. Please note, Penicillin IV has been given as a stat
dose.

Yours sincerely.

Dr. Lucy Irving

Referral letter – prostate cancer

Read the cases notes below and complete the writing task which follows

Time allowed: 40 minutes

Today's Date

15.08.09

Patient History
Darren Walker

DOB 05.07.69

Regular patient in your General Practice

09.07. 09
Subjective
Regular check up, Family man, wife, two sons aged 5 and 3
Parents alive - father age 71 diagnosed with prostate cancer 2002.
Mother age 68 hypertension diagnosed 1999.
Smokes 20 cigarettes per day –trying to give up
Works long hours – no regular exercise
Light drinker 2 –3 beers a week

Objective
BP 165/90 P 80 regular
Cardiovascular and respiratory examination normal
Height 173 cm Weight 85kg
Urinalysis normal

Plan
Advise re weight loss, smoking cessation
Review BP in 1 month
Request PSA test before next visit

14.08.09
Subjective
Reduced smoking to 10 per day
Attends gym twice a week, Weight 77 kg
Complains of discomfort urinating

Objective
BP 145/80 P76
DRE hardening and enlargement of prostate
PSA reading 10

Plan
Review BP, smoking reduction in 2 months
Refer to urologist – possible biopsy prostate
Writing Task

Write a referral letter addressed to Dr. David Booker (Urologist), 259

Wickham Tce, Brisbane 4001. Asl to be informed of the outcome.

In your answer:

* Expand the relevant case notes into complete sentences

* Do not use note form
* The body of the letter should not be more than 200 words
* Use correct letter format

Sample letter

Sample Model Letter 1

15/08/2008

Dr. David Brooker (Urologist)

The Urology Department
259 Wickham Tce,
Brisbane, 4001

Dear Doctor,

Re: Mr. Darren Walker

I am writing to refer this patient, a 40 year old married man with

two sons aged 3 and 5, who requires screening for prostate cancer.

Initial examination on 09/07/09 revealed a strong family history of

related illness as elderly father was diagnosed with prostate cancer
and mother was diagnosed as hypertensive. Mr Walker is a smoker
and light drinker. He works long hours and does not do any regular
exercise. His blood pressure was initially 165/90 mmhg and pulse
was 80 and regular. He is 173cm tall and his weight, at that time,
was 85 kg. He was advised to reduce weight and stop smoking and
a prostate specific antigen test was requested. There were no other
remarkable findings.

When he came for the next visit on 14/08/2009, Mr Walker had

reduced smoking from 20 to 10 cigarettes per day and was
attending gym twice a week. He had lost 8kg of weight. His blood
pressure was improved at 165/90mmhg. However digital rectal
examination revealed an enlarged prostate and the PSA reading was
10.
In view of the above signs and symptoms, I believe he needs
further investigations including a prostate biopsy and surgical
management. I would appreciate your urgent attention for his
condition.

Yours sincerely,

Dr.X
Transfer letter – rehabilitation

Notes
Model letter

Paragraph one: patient / condition / request

Details: Patient – Mr Mc Donald. Condition – total left knee joint replacement

operation. Request – rehabilitation

Thankyou for accepting Mr Mc Donald, who has recently undergone a total left knee joint
replacement operation performed by specialist Mr B Mossley, for rehabilitation.

Paragraph two

Details: osteoarthritis (past 10 years), gout (since 2010), smoker – 20 cigarettes/day,

hypertension, obesity – BMI 35, hypocholesteremia, alcohol > 6-10 SD/day, penicillin
allergy as a child

Mr Mc Donald has been suffering from osteoarthritis for the past 10 years and was
diagnosed with gout since 2010. He is obese (BMI 35), has hypertension and
hypocholesteremia, and he smokes and drinks alcohol excessively. Furthermore, as a
child, he experienced a rash after taking penicillin.
Paragraph three

Details: Discharge medications are Zyloric, Karvina, Lipitor, paracetamol, ibuprofen,

and a nicabate patch (please see the attached list of dosages)

Paragraph four

Details: significant post operation pain, morphine inadequate, ketamine infused, ongoing
pain following, amitriptyline commenced – ceased due to urinating difficulty, slow to
mobilize partly from pain, catheter specimen of urine (CSU) – Staph. Saphrolyticus,
keflex given in addition to antibiotics, insomnia noted

Mr Mc Donald complained about significant post-operation pain, which couldn’t be

relieved by both morphine and ketamine, so amitriptyline was administered, but was
eventually stopped because Mr Mc Donald experienced urinating difficulties. Mr Mc Donald
also displayed limited mobility due to pain. The catheter specimen of urine revealed
that Mr Mc Donald was infected by Staph. Saphrolyticus for which he was treated with
Keflex and antibiotics. In addition, Insomnia was noted.

Paragraph five

Details: Treatment plan – review of system, specialist at 6 week (appointment made

7/9/18), significant rehab including physiotherapy and occupational therapy home visit
to assess suitability and fitness of returning to caravan, social work, drug and alcohol
input appreciated, sleep studies? OSA

I would appreciate if you could conduct a thorough review of system on Mr Mc Donald.

Please provide a rehabilitation, including: physiotherapy and occupational therapy home
visit, to ensure that Mr Mc Donald’s condition is fit enough prior to allowing him to
return to his caravan. Both social work, drug and alcohol counselling, and sleep studies
should be also incorporated if possible.

Please note that Mr Mc Donald has an appointment with Mr Mosley 6 weeks post-operatively
on 7/9/18

Should you have any questions, please do not hesitate to contact me.