WRITING SUMMARY FOR

OCCUPATIONAL ENGLISH TEST

OET 2.0

Dr Samed Alsalemi
Occupational English Test - OET 2.0

WRITING TEST (45 Minutes)

The Writing sub-test will take 45 minutes to write one letter Specific to profession, based on typical
workplace situations. The common formats used by OET include:
 Usually a referral letter
 Referral from GP to Duty Registrar in Hospital
 Referral from GP to admitting doctor in Emergency Department
 Referral from GP to specialist
 A transfer letter
 A discharge letter from GP to a community doctor
 A letter of explanation, requesting or giving advice.

The important point is to always read the task question carefully and respond appropriately.

Candidates are assessed against the following criteria:

1. Overall Task Fulfillment
2. Appropriateness of Language
3. Comprehension of Stimulus
4. Linguistic Features (grammar and cohesion)
5. Presentation Features (spelling, punctuation, layout).

Handy Hint

Do not just summarise the medical history. Always consider what the referred to person needs to
know and what they will do with information. The social factors are sometimes very significant,
hence the need for ongoing care, and are included to make the task more complex and
challenging for the candidate.
Task types
Letter Type Chief Complaint & Purpose Complicating factors in case notes
of Writing
 Referral from GP to Duty Registrar in  Meningococcal  Complex social factors including
Hospital meningitis language barrier
 Detailed and long medical history

 Referral from GP to Pyschiatrist  Schizophrenia  Complex social factors

 Medical history

 Referral from GP to admitting doctor  Peritonitis  Significant medical history

in Emergency Department  Urgent case
 Socio-economic situation of
 patient

 Referral from GP to Gynaecologist at  Fertility problem  Confidentiality

a Fertility Clinic  Conflicting views of husband and
wife and GP
 Detailed medical history

 Referral to school psychiatrist  Behavioural problems in  Social factors leading to psychiatric

child since death of problems
father  Focus on social not medical history

 Referral from GP to Consultant  Antenatal care  Only one very detailed

Obstetrician at a Mother's Hospital consultation

 Referral from GP to Endocrinologist  Diabetes  Complex social history

 Long medical history

 Referral from GP to Neurosurgeon  Subdural haematoma  Urgent situation

 Detailed social and medical history

 Referral from GP to Pyschiatrist  Anorexia Nervosa  Complex social history

 Referral from GP to Urologist  Severe hydronephrosis  Detailed medical history

 Urgent situation
Common stages in the writing task
Key stages in the writing task
Analysing the task to be clear that you are
providing the appropriate information - e.g. your
choice of information could be different for
different readers
Reading the case notes to identify:
 the main purpose of the referral - what do you
want the reader to check or know?
 information which could be relevant to the
reader when making their decision
Organising the information into a cohesive
(unified and interconnected) whole
Writing the letter out in full with attention to the
details of English
Main language focus of each stage
.
Identifying the audience and how that affects content
This includes length - the 200 word limit means you will
need to make careful decisions about leaving out
information while still maintaining enough information for
the reader to base an assessment or action on.
Focus on meaning—this will generally be straight forward,
but it's a good idea to check.
Reading and highlighting the key information
Focus on meaning .
Writing a plan
Focus on meaning and overall text organisation.
Focus on language forms - using grammar and vocabulary
appropriate to formal letter writing.
WRITING STRATEGIES
1 –Know the instructions and format before Test Day, so you know what to expect:
 You will always be given task instructions
 You are given stimulus material (case notes and/or other related documentation)
 You are given a patient’s case notes and from them you extract the relevant information.
 You write in the printed answer booklet provided, which also has space for rough work.
 You can use either a pen or a HB pencil.
 READING TIME: 5 MINUTES AND WRITING TIME: 40 MINUTES
 5 minutes reading time, during which you can’t take notes or underline any details
 40 minutes to read the task and write your letter in a booklet provided. You can use pen or pencil.

2 –Read the TASK carefully (Analyze the task)

Start by reading the writing task section at the end of the test (30 seconds) This will inform you of the
task , including who you need to write to, and what you need to say beside Headings and Endings:
1. Who is the patient?
2. Who will the letter be addressed to? Who am I writing to /The recipient’s position/profession
3. What are type of letter you must write: referral, discharge, transfer or information?
4. Where must the letter be addressed ? The recipient’s place of work and address

3–Scan the Case Notes Actively (interpreted the case notes)

You should spend the whole 5 minutes reading time scanning the patient case notes carefully,
Interpreting correctly and identifying relevant information.
1. Read through the case notes. See what’s your role? who you are in relation to the patient?
2. Continue reading through the case notes. Find what’s relevant to your letter ?
3. Focus on the main problem. Find what’s most point you must to communicated to the reader?
4. The secondary issue - medical /social. Find supportive information you must give to reader?
5. Read the history , treatment, medication. Find the information background useful to the reader?

Please note, you are unable to underline key words or phrases during the 5 minutes’ reading time
4 – Selecting relevant case notes:

 What’s information ones are important, and which ones are unimportant to the reader?
 You have to make decisions about which case notes to include and which case notes to ignore.
 Plan how many case notes you should include in order to write an appropriate length.
Considering the body of your letter should only be between 180 and 200 words, you simply cannot –
and you certainly should not – include all of the case notes.
For example, if you are writing to a doctor about a patient’s diabetes don’t include that they broke
their wrist twelve years ago. It’s completely irrelevant.

5 –Plan Your Response (Writing a plan): Organizing case notes logically and coherently

 Write with a pencil so that you can erase any mistakes also use a highlight pen and highlight related
points with the same colour pen to help you summarize and group the information
 Think about how best organize your letter before start writing.
I advise 5 minutes of planning, which still allows 35 minutes to write the letter.
 Keep your plan brief and write in note form.
 Use the space provided to plane your letter

Once the writing time starts, the next stage is to plan a letter by outlining the structure of your letter.
‘Organising case notes’ and the following step ‘transforming case notes’ happen simultaneously while
you write. In other words, as you organize case notes into logical paragraphs you will also be
transforming them into accurate sentences.

The structure of your letter is critical for success. In short, it needs to be ‘readable’, not just
grammatically, but it should flow from beginning to end in a coherent and logical way.
Once you’ve decided on the points you will cover, you can begin to add to each point from the case
notes.

Sketch out a simple paragraph structure before you start writing because once you start writing it’s
very difficult to restructure, for you are writing on paper not a computer.
Although there’s no ‘set structure’ for OET writing, there are some guidelines that you should keep in
mind when organising your letter. A format which will fit most scenarios is as follows:
 Introduction: The introductory sentence/paragraph
 Including purpose of writing the letter (i.e. refer, discharge, transfer)
 The main medical issue ( chief complaint / current situation) in brief.
• Paragraphs :Single ‘themes, non-mixed information, not confusing and structured coherently.
 Paragraph 1: Patient social and past medical history in summary
 Paragraph 2: Patient medical history
 Paragraph 3: Patient current situation in detail
 Conclusion: Concluding request specific to the task

A good paragraph will contain 3 main elements

1. A Topic Sentence which introduces the reader to the main idea of the paragraph.
2. Supporting sentences which may contain the detail regarding patient history, descriptions of
symptoms, significant aspects from the treatment record, causes and effects, trends and so on.

3. Signal words link sentences together so that the information flows smoothly and is easy to read.
Common signal words which can help you present information clearly and logically include:
 Time: At that time, On review today, On consultation today, Recently, Over the past 3 weeks....,
 Location: During hospitalization, Initial examination at my clinic revealed...,On examination....
 More information: In addition, Moreover, Also, Apart from this.
 Contrast: However, Despite, Although.
 Result: Therefore, Consequently, As a result, For this reason...
 Emphasis: Please note, May I remind you, My main concern is...., What concerns me most is.....
 Sympathy: Unfortunately, Regrettably, Fortunately.
 Subject: In terms of her social history..,With regard to her medication.., Regarding her medical history
 Advice: It is important to..., I recommend that you....., Please ensure that....
 Chronology: Firstly, Secondly, Finally.
The keywords in the case notes are the words and phrases that relate to the purpose of the letter
you need to write, begin planning your letter by ask yourself the following questions as you plan:
1. Who are you writing to?
• Specialty of the doctor will change the way you write your letter.
2. What is the chief complaint/current condition or purpose of the letter?
3. What do they need to know?
• Does the doctor already know the patient or first time to see the patient?
4. What do they know already?
• If already know the patient ,avoid using information from case notes that are already know.

As you continue to plan your letter, think where the different parts of information might appear.
The case notes you are provided with will not necessarily present the information in the best order .
It might be best to think about three or four broad points that you want to cover.

For example, when writing a letter of discharge, you might want to discuss:
1. Why the patient was under your care.
2. How the patient was treated.
3. When the patient’s current situation will change (if they are being discharged or referred).
4. What the patient’s current state is, and what the patient’s current treatment is.

When writing a letter of admission, you might want to discuss:

1. Why the patient was under your care.
2. How the patient was treated.
3. What the patient’s current condition is.
4. Current/future treatment?

if you need to write a letter referring the patient for further assessment
1. you should look for words in the case notes that relate to treatment.
2. The information in the case notes that relates to past medical history is likely to include
information that is not relevant to your letter.
Example task ”: Letter of referral to rehab facility:

As an example, you might create the following plan for a letter of referral using the case notes about
Lydia Frank on the previous two pages. Please note that you should avoid spending more than 5
minutes planning so you may not be able to develop such a detailed plan on Test Day.
care unit (NICU) to the neuro telemetry unit.
Ms Lydia Frank is a 49-year-old female who was transferred from the neuro intensive care unit
(NICU) to the neuro telemetry unit
Lexington Hospital
Patient details:
Name: Lydia Frank
Marital status: Divorced for 8 years
Darlene (daughter – 24-years-old,
Next of kin:
unemployed)
Admission date: 20 January 2018
Discharge date: 13 April 2018
Diagnosis: Subarachnoid hemorrhage (SAH)
Past medical history: Hypertension (2015)
Hyperlipidemia
Migraine
Anxiety and depression
Smoker (approx. 10 cigs per week)
Works full time–accountant, financially
Social background:
independent.
 Found unresponsive at work. Complaining of
Presenting Complaint: “worst headache ever”.
Admission 20/01/2018
Vomitus present. SAH. Pupils equal, round +
Assessment:
reactive to light.
BP 220/110 mm Hg. Endotracheal intubation
performed (weaned from
mechanical ventilation week 2).
No supplemental oxygen required
Craniotomy and endovascular coiling performed
to treat SAH
Developed central line-associated bloodstream
infection and urinary tract
infection – multiple rounds of IVantibiotics.
Oriented to person, place, time, and situation -
21/01/2018:
slow to respond.
BP very unstable.
Antihypertensive medications adjusted 5 times
since admission (currently
taking clonidine PRN, scheduled lisinopril,
scheduled labetalol).
BP within normal limits (145/90-150/80 mm Hg -
one week)
No reports of headache 1/7. Left-sided weakness
slowly improving.
Nursing management: Neurologic and BP checks every 4 hours.
Encourage patient to be seated in bedside chair
for meals (→ requires 2
assists to pivot from bed to chair secondary to
left-sided weakness).
Requires assistance with feeding.
Nectar thick liquids required.
Medications crushed with apple sauce.
Assessment: Good progress overall.
Discharge to rehab facility, continue nursing
Discharge plan:
management as above.
Plan Response : Lydia Frank (F) to rehab facility
Why was F admitted?
 NICU 20 January 2018 – because subarachnoid hemorrhage (SAH) at work.
 unresponsive and receiving mechanical ventilation
What was treatment?
 2nd week taken off mechanical ventilation - made good progress
 at 1st - craniotomy + endovascular coiling – SAHMs.
 Treatment complicated - central line-associated blood stream infection + urinary tract infection
Current condition
 F without infection good cough effort, no supplemental oxygen req.
 aware of person, place, time, situation – BUT slow respond.
Current/future treatment?
 F’s blood pressure now controlled - scheduled lisinopril, scheduled labetalol, + PRN clonidine .
 crushed with apple sauce
 nectar thick liquids a must
 needs assistance 2 people - pivoting bed to chair + ambulation – left sided weakness.
 BP + neurological checks every 4 hours

Notice that the plan breaks the letter out into four separate sections, and uses information from
the case notes to support each section.
6 –Writing your letter (Transforming case notes)

Once you’ve outlined the structure of your response, you can move on to writing the letter itself.
Read through the following strategies to familiarize yourself with the type of letter you must write.

General Advice:

1. Before you begin writing, underline all the information in the notes that you think is relevant to
the specialist you are referring to.
2. Give each idea its own paragraph. Each paragraph should be no longer than 4 -5 lines.
If you want to save space on your answer sheet, indent the beginning of the first line of each
paragraph. Some students think that they have broken up their answer into paragraphs, but if the
examiner can't see the beginning of each paragraph, you will lose marks for Control of Presentation
Features.
3- Practice writing neatly. There is no marking criteria for handwriting, but if the examiner is unable to
read your handwriting, you have failed to communicate effectively and your Overall Task Fulfilment
and Control of Presentation Features criteria may suffer as a result.

Common mistakes with medical Collocations (words that should go together)

Right Wrong
I am writing in regards to + [noun]
I am writing in regards of + [noun]
I am writing regarding + [noun]

admitted to hospital admitted in hospital

due to + [noun] e.g. "due to his illness" due to + [sentence] e.g. "due to he is still not well."

diagnosed with + [name of disease] diagnosed of + [name of disease]

TIPS & TECHNIQUES: Follow these tips to improve your performance:-
 Take the time to understand the situation and the requirements of the task.
 Always keep in mind the reason for writing ( why you are writing and who you are writing it for).
 Try to write between 180-200 words and avoid copying parts of the question or notes.
 Use your own words as much as possible –don't simply copy sections from the case notes
 Show awareness of your audience by choosing appropriate words and phrases:
 if you are writing to another professional, you may use technical terms and, possibly, abbreviations.
 if you are writing to a parent or a group of lay people, use non-technical terms and explain carefully
 Be clear what the most relevant issues for the reader are.
 Don't include information that the intended reader clearly knows already (e.g., if you are replying to
a colleague who has referred a patient to you) -Don't include so much supporting details.
 Organize the information clearly "I.e. the sequence of information

 " Use paragraphs where appropriate. Remember, each idea should have its own paragraph.

 Highlight the main purpose of your letter at the start

 Be clear about the level of urgency for the communication
 Focus on important information that the reader needs to know and minimize incidental detail
 Write as neatly as possible. The examiner must be able to clearly read your writing.
 Consider using dates and other time references (e.g., three months later, last week, a year ago) to
give a clear sequence of events where necessary
 Write in a formal style -Avoid informal language (e.g., use "Thank you‟ rather than "Thanks a lot‟)
 Avoid using slang language, abbreviations or SMS texting abbreviations i(e.g., use "you‟ not "u‟)
 Give the correct salutation: if you are told the recipient's name and title, use them
 Try to use complex sentences where it is appropriate. If your sentence is too long or complicated,
break it down into more simple sentences.
 Check your writing for spelling mistakes, punctuation and grammar errors.
 Do some practice tests before you sit your exam.
 Dos & Don’ts
Below is a list of simple points to remember on the day of your exam.
Do
Summarise all the information from the case notes
into sections such as: treatment given and obvious
trends, medication, medical history. This will be
both easier to write and read as well as avoiding
repetition
Try to write somewhere between 180 and 200
words for the body of the letter. This is the
requirement of OET and the assessors are quite
strict in this area.
Omit information which is not directly relevant to
your task. This is a big trap for many candidates in
that they try to write down all the information
from the task sheet. This does not reflect reality.
Expand on all acronyms. For example OPG should
be written as orthopantamogram, BP as blood
pressure and PR as pulse rate & hx as history
Provide a simple clear summary of the condition so
that a lay person could understand
Spend time reading the case notes and grouping
information which are related such as medication,
persistent high blood pressure etc etc
Use synonyms so that you can express the
information from the case notes in different ways
Allow 5 minutes at the end of the test to proof
read your work and fix up any mistakes
Don’t
Follow a strict chronological order as your letter
may become too long, difficult to read and will
not focus on the main problem and related
factors.
Write over 220 words as it will affect your overall
result. You are being tested on your ability to
write a clear concise letter, not a long letter.
Don’t write under 160 words as there may not be
sufficient language to get a B grade.
Try to put all the information from the case notes
into the letter. Your letter will be too long and
also poorly organised and difficult to read
Overuse acronyms. You are being tested on your
ability to expand on case notes so make sure you
do.
Use too much medical jargon. Remember it is a
test of English not Latin!
Start writing without planning your letter. You
should allow 15 minutes reading case notes and
planning the letter.
Copy directly from the case notes without any
changes. You are expected to put the information
into your own words.
Submit the letter without checking for basic
mistakes such as grammar/spelling.
Keep in mind the OET assessment criteria when you are writing.
1: Overall task fulfilment
2: Appropriateness of language
3: Comprehension of stimulus
4: Control of linguistic features (grammar and cohesion)
5: Control of presentation features

Your writing is marked by two trained markers who look for:

 Objective Writing : Writing that contains factual information (not subjective) that is being reported.
 Good Grammar and Spelling
 Overall task fulfilment : (Have you done all the given tasks?)
 Cohesion in Writing :Writing that shows relevance to the case study and develops logically.
 Appropriate use of Words: (pronouns, adverbs, phrasal verbs, conjunctions, modals).
 Correct Formatting : That the letter has clear blank lines between paragraphs, is dated and the body
of which is no more than 25 lines long.

A comprehensive yet concise letter would be one that has:

 A date
 A short introduction
 An outline of the patient’s past medical history
 Reports on the patient’s past medications.
 Outlines the patient’s current medical history
 Reports on the patient’s current medications.
 Includes any social particulars that may be relevant (eg: patient lives alone).
 Mentions particular needs of the patient (eg: needs a walking frame).
 Includes a paragraph setting out why the patient is being referred.
Overall task fulfilment
 This final step is to transform the case notes to tell a story to the reader.
 You are taking the case notes and re-working them so that they make sense and fulfill the task.
• The selected case notes must be relevant to the reader
• your content, structure, language and tone need to be meet the needs of who you’re writing to.
• Your letter should always begin by giving the date, the address and name or occupation of the person
you’re writing to, and a greeting to the person you’re writing to.
• you should aim to write between 180-200 words in the body of your letter (after ‘Dear___’ and before
‘Yours sincerely’). There is no need to count the exact number of words you have written but it is a
good idea to know roughly how many lines of your handwriting are 180-200 words. You can work this
out by counting the words of one full line of your writing and then dividing 200 by this number to give
you the number of lines. Falling outside of this word range does not necessarily mean you’ll score
poorly in this criteria. If you have written more than this, check you have included all relevant
information and left out all irrelevant information then edit accordingly.
You must also make sure that you are writing the type of letter specified in the task. Pay close
attention to what this section says, and build your response around the task. Don’t try to prepare a
response before looking at the task, or try and memorise a letter that you can reproduce on Test Day,
as this will not show that you are able to respond appropriately to the task that is given.
• You should also avoid copying entire phrases exactly as they appear in the case notes. This is not a
good plan for two reasons:
• The phrases used in the case notes are in note form. They are generally not appropriate in their
current state for a letter, so you must expand these phrases, in order to write in an appropriate
style, e.g. Demonstrate your skills by writing a letter that incorporates the relevant facts
appropriately and in your own words. (Paraphrasing)
• The assessor can also see the case notes. If you copy the language in the case notes exactly, the
assessor will not be able to assess your understanding of the case notes, or your writing ability.
• You must not make up patient history, or propose treatment options if not given in the notes.
• Do not write additional patient information into your letter which is not contained in the notes
• Do not include any information from the patient case notes that is not relevant to the letter.
• Aim to complete your letter at least 3 minutes before the end of the test, so that you have time to
read through your letter and correct any mistakes.
Mistake Correction

1. minor social history is written in the
body of the letter
Write it in the Re section e.g. Re: Mrs. Joan Smith, 45 years old,
married, two children.
The Re section is not counted so you save words. HOWEVER, if some
social history is important e.g. if an emphysema patient is a smoker,
the fact that he smokes should be written in the body of the letter.

2. abbreviation The use of abbreviations is a difficult issue. In general, you can use
common abbreviations like BP, ECG etc.
but abbreviations like “b.d”. should be expanded to “twice a day” IF
you know the meaning. Luckily, there are less abbreviations in recent
OET writing tasks. So, if there is an abbreviation and you don’t know its
full meaning just copy the abbreviation.
Another strategy is to write the word in full the 1st time followed by the
abbrev in brackets e.g. “congestive cardiac failure (CCF)” then each
time after that write “CCF”.

3. you have written If you write the person’s full name in the Re: section you just need to
the patient’s / customer’s full name write the person’s surname in the 1st sentence. E.g. Re: Mr. John
in the 1st sentence. Smith, 46 years old, married.
1st sentence: “I am writing to refer Mr. Smith who is suffering from…”

4. Mr. John In English you would rarely write or say Mr. John.
Use Mr. Smith or John (if the patient / customer is under 18 years old).

5. wrong title e.g. Mrs. Smith used for Use Mrs. for married women, use Miss for single women and/or girls
a single woman BUT you can use Ms. for EITHER a married woman OR a single woman.
It is the choice of the woman concerned.

6. overused expression e.g. My main The expression is not wrong but it is used by nearly every candidate.
concern is…” Write something different e.g. Please be aware that the patient
requires…” Please note that…

7. the exact words have been copied Try to use synonyms to show the examiners that you have a broad
from the task / case notes range of vocabulary BUT don’t waste time thinking of synonyms. If you
are running out of time use the same words.

8. no date written You must write a date on your letter / information sheet. Usually the
date is the date of the last consultation / the day of discharge / when
you spoke to the customer in your pharmacy.

9. Uncommon usage e.g. “difficult It’s much more common to write “The patient reported difficulty
sleeping” sleeping.”

10. Incorrect use of “ago”
“ago” is used to indicate the recent finished past e.g. (If today is
Monday.) “Two days ago I went fishing.” This means I went fishing on
Saturday. (If today is 1st May.)
“The patient presented on 1st of February and reported a headache two
days ago.” This means he/she had a headache on 29 April. Use
previously or earlier instead of ago
Appropriateness of language

• Make sure the tone of your writing is formal and appropriate.

• Abbreviations and medical terms used appropriately but not used as a shortcut grammatically.
For example, “Her BP 126/75, P 72
• Letter tasks in the Writing Test will always ask you to write letters in the role of a healthcare
professional. As such, you should always use a suitably formal tone in the writing section.
• If you’re writing to another healthcare professional, use medical terminology where relevant.
• If you’re writing to a layperson, such medical terminology should be avoided.
• You should avoid using casual language or idioms (‘how’s it going?’), and write in full words, rather
than contractions (‘can’t’ ‘isn’t’) or SMS text abbreviations (use ‘before’, not ‘b4’)
• You must ordering the information (emphasised and expanded on the very important points)
• the letter must be organised clearly where the salutations, titles and main purpose is clearly stated
If you’re writing a letter of referral, you might begin your letter with a sentence like .
Joanna Howards will be discharged to your Nursing Facility on 12 October 2018.
Note that in this example we included the date, to make sure that the most important information is
provided to the recipient of the letter in the first sentence.

You should also include dates, times and time periods throughout your letter, and use language that
clearly sequences the time-period of the information, in order to provide a clear order to your letter.
For example, instead of writing
The patient was diagnosed with cancer of the oesophagus and had an oesophagectomy and
chemotherapy and lost a considerable amount of weight.
You could say something like this:
The patient was diagnosed with cancer of the oesophagus on 24th April. Chemotherapy was
scheduled to begin in the following week and last for a total of three weeks. The patient lost a
considerable amount of weight as a result of this treatment. An oesophagectomy was then
successfully carried out on 3rd June.
Look at the various ways the second example links the different pieces of information, and allows
reader to see the sequence of the events more clearly.
If the task requires you to write an urgent letter, you should make this clear in your letter, too. An
urgent letter may also require you to change the structure of the letter, for instance, you would need
to put the patient’s current condition at the beginning of an urgent letter

if the letter was not urgent, it might be more appropriate to begin with the patient’s history.
The tone of your letter should always take into account your audience and the purpose of your letter.
You can only use 180 – 200 words in your letter, so there is not enough room for you to include any
unnecessary details.

Mistake Correction
1. informal language
I really appreciate your ongoing management ... I greatly appreciate ... (greatly is more formal)

2. I ordered some tests. Some tests were ordered. (passive voice is more formal than
active voice)

3. Mr. Smith is an alcoholic. These examples are too emotive (and not formally accurate).
Better choices include:
.
Mr. Smith's alcohol intake is above the recommended
levels, OR Mr. Smith's alcohol intake is excessive. (The 2nd
one is better if you need to save words.)
4. Mrs. Smith is fat Mrs. Smith's weight is significantly above her ideal weight
range, OR Mrs. Smith is overweight or obese.

5. Using she/he in the 1st sentence of a paragraph. Write the patient's name or 'the patient' because the first
sentence in a paragraph is the most important sentence.

6. NURSES – inadequate 1st paragraph he 1st p/g should answer the questions who?, why?, what?,
where? when? e.g. Mrs Smith was admitted two days ago for
a hip replacement. She will be
discharged tomorrow.

7.too direct e.g. Mrs. Smith will be seen by a social Kindly arrange an appointment with a social worker.
worker.
 Comprehension of stimulus (The “tasks’ you have to do)
Have you understood what you have to do? And why? Can you filter out unnecessary / irrelevant
information in the case study that does not necessarily impact on the patient’s recovery?

• you need to show that you have understood the case notes. You can do this by using the case notes
appropriately to create a letter that fully addresses the task.
• Rather than trying to use as many case notes as possible, think about what the individual you are
writing to needs to know. If you include information that is not relevant to the task, you will receive a
lower score, so only include it if you think it is relevant to your letter. If you include too much
surrounding detail, then it will also make it difficult for the assessor to assess that you have
understood the task.
• Put the case notes into your own words wherever possible, and connect the case notes together
appropriately. Remember, you should not add any information to your letter that is not included in
the case notes.

Mistake Correction

The main thing to remember in this criterion is to INCLUDE important

information and EXCLUDE unimportant information. So, the question to ask
1. yourself is: “What does the reader need to know in order to treat (or care
for) this patient?”

Only include POSITIVE examination findings HOWEVER sometimes the reader

2. you’ve included all the normal vital will need to know NEGATIVE findings e.g. with an anorexic patient, the
signs and test results. thyroid function tests are normal / neg so the reader will need to know this.

3. misunderstanding of the case notes
/ task
E.g. the reader of the letter is a patient’s parents but you write to another
health professional instead e.g. “The patient is 8 years old and he suffered a
minor fracture…” The parents know this information. OR you
write that a patient’s condition is caused by e.g anxiety
which is the patient’s opinion but it is not stated on the case notes.
Check Your Letter for Errors
Once you have finished writing your letter, you should make sure to check through what you have
written and correct any errors. Once you have looked through your letter and identified your errors,
make a list of your most common errors, and make an effort to target these areas in particular, before
completing another writing task. For example, if you commonly make article errors, make sure to revise
the correct articles to use, for example, you should use ‘in the bloodstream’ rather than ‘in
bloodstream’, and ‘a heart attack’ should be used, rather than ‘an heart attack’.

Be careful about fatal mistakes

 3 mistakes in grammar , 3 mistakes in Punctuation or other 4 different mistakes
 More than 5-7 errors in the letter will reduce your chance of getting a B grade or higher
Control of linguistic features (grammar and cohesion)

Make sure that you show that you can vary your language while writing the task. Where possible, use a
range of tenses, grammar and vocabulary to demonstrate your writing skills.
• Use articles (definitive/ indefinite) (She had an operation ,On the Internet)
• Countable ,uncountable ,singular & plural Nouns (some evidence, an opinion, don’t write an asthma)
• You can use simple sentences, but you should also use complex sentences too (mixed).
Use conjunction …….; thus …// therefore,……. later on, - long and short sentences conjunctions.
When you read through your letter, look at the length of the sentences you use.
• if you have a lot of very long sentences, you might want to split this content up into smaller
sentences, or remove information that is not necessary, to make sure that your writing is controlled.
• If you have lots of short sentences, consider using connectives to join some of these sentences into
longer, complex sentences
 Compound Sentences : These are sentences which contain 2 or more clauses linked
together using a coordinating conjunction (and, but, so, or, for, nor, yet).
 Complex Sentences: These are sentences which contain 2 or more clauses linked together
using a subordinating conjunction (although, as, because, if, since, when, where, while).
 Complex Compound Sentences: These are sentences which contain both coordinating and
subordinating conjunctions. This means they will contain at least 3 clauses

 Maintaining consistent structure of words when linking different phrases .“parallelism”,

• linked sentences together into paragraphs to maintaining consistent structure - Cohesive
Use furthermore ,in addition , moreover”, consequently , therefore , as a result ,however, but.

• Use relative clauses and pronouns

• Use verb - Tense verbs usage
• Use the past to talk about patient care in past (for example, what has been done so far)
• Use the present (for example, the patient’s current care plan)
• Use the future (for example, how the patient’s treatment should progress).
• Use passive voice e.g. Not "I arranged a blood test." better: "A blood test was arranged."
• Use reported speech
• Use modals
• Use adjectives
• Use Adverbial phrases :
• Please note, ….
• On 15/01/2018,
• Today, Ms.… came reporting that (to) ... Thus, ...

• Agreement
• Subject/verb agreement: The sutures has been removed. The suture have been removed.
• Number agreement: The test result shows that…,there is no evidence.., he lives.., one of side effects
• Gender agreement : Mr Jones and her daughter. Mr Jones and his daughter
• Tense agreement: Examination on 15 May 2006 revealed she overweight/not .. she is overweight

• Adverbs and Adverbial clause that give time reference:

• Two months previously is not same as two months ago.

• Use of prepositions/ phrasal verbs and prepositions.

 Thank you for seeing /not ….to seeing
 Sensitivity to pressure /not ….of pressure
 My examination of the patient /not…. on the patient
MISTAKE CORRECTION

Write a/an in front of all COUNTABLE nouns the FIRST TIME you write
1. missing “a” or “an” or “the” them. The second time you mention them, use the e.g. Mrs. Smith
underwent an operation yesterday. The operation was a success.

Write “the” OR “his” OR “her” in front of all body parts e.g. “Mr. Smith
2. missing “the” or pronoun before sustained fractures to the ribs.” “I sold Mr. Smith a medication for pain in
the object of the sentence the knee.” An exception is: “a fractured femur.” BUT “ a fracture of the
femur”

Write “the” when the noun is understood to be PARTICULAR by the reader

e.g. “The fridge is not working.” Everyone knows that you are talking about
3. missing “the” your fridge in your house. E.g. “For the reasons above…”. The reader knows
which reasons you are referring to. Also, “the pill”, everyone knows you are
referring to the OCP.

4. no “the” in front of a superlative

Always write “the” in front of a superlative e.g. ‘the most effective”, “the
e.g “Most effective medication was
biggest”, “the smallest”
recommended.”

5. unnecessary article used e.g. She “vision”, in the example, is an UNCOUNTABLE noun like “advice”, “water”
complained of a blurred vision. etc. so do not use an article. “She complained of blurred vision.”

The FIRST time you mention most nouns they are still GENERAL e.g. “heart
6. unnecessary article used e.g. The
disease” or “advice” so no article is necessary but the SECOND time write
patient presented with the
“the/his heart disease is not responding…” or “the advice to give up smoking
Msymptoms indicating the heart
was not followed…” because the nouns then become PARTICULAR. (This
disease.
differs from C3 above.)

Write “furthermore” or “in addition” or “moreover” etc as you are ADDING

7. no joining word
more, similar information.

Write “consequently” or “therefore” or “as a result” etc. as there is a result

8. no joining word of an earlier action.
 Write furthermore or in addition or moreover, and, etc. when adding
more, related information to the previous clause/sentence.

Write consequently or therefore or as a result to indicate that

something happens because of what you have mentioned in the previous
clause/sentence.
9. no joining word
Write however, but, etc. as there is some contrast / difference.
to indicate that you are presenting information that contrasts the
information in the previous clause/sentence.

Write In view of the above, ... to indicate that you are about to make a
suggestion or give an opinion based on the information you have
presented earlier.

Write “In view of the above…” OR “In light of the above…” OR “Given the
10. no joining phrase to summarise
above…” in the last paragraph as it brings the whole letter together and
the letter
creates cohesion.

Simple present to describe facts that stay the same for a long time .NOT
“She HAD a history of…” write “She HAS a history of…”. e.g.

11. SIMPLE PRESENT tense not used The tests show that Mrs Jones has a respiratory disease.

Present continuous to describe a patient's currently uncompleted

treatment e.g. Mrs Jones is undergoing radiation therapy.

“Thank you for seeing Mrs. Smith who presents with X.” You must use simple
12. SIMPLE PRESENT tense not present tense in this sentence as the presenting complaint is the reason you
used in the 1st paragraph are referring the patient i.e. the last consultation is when the patient has X.
Also, the last consultation is the date of the letter.

When you have two pasts use past perfect e.g. “Yesterday the patient
reported the pain HAD worsened.” “reported” was yesterday so use simple
13. PAST PERFECT not used past. The worsened pain happened BEFORE the reporting of the pain so it’s
an EARLIER PAST so use past perfect.
 Present perfect Use present perfect tense when there is a connection
between the PAST and the PRESENT. E.g. to describe aspects of a patient's
14. PRESENT PERFECT not used history that continue to have an effect in the present e.g.

Mrs Jones has completely recovered from her operation. (Note the
placement of the adverb between the two parts of the verb.)

Mrs. Smith HAS HAD an uneventful recovery so she will be discharged today.

Simple past to describe aspects of a patient's history that were

completed in the past e.g.

15. SIMPLE PAST not used Mrs Jones had a major operation in 2002.

Mrs. Smith HAD a fall yesterday. The adverb “yesterday” places the fall in
the finished past i.e. there’s no connection with the present.

On examination, a rash and ankle oedema were noted As more than one
16. number agreement
sign/symptom were noted use “were”.

The patient’s (OR Her) past history is unremarkable. In the “real world” you
17. not a full sentence / note form
would write sentences in note form but in the OET be safe and include verbs,
e.g. Past history is unremarkable.
articles, prepositions etc.

18. no “and” before the last item in

The patient reported headache, painful joints, nausea AND constipation.
a list
19. incorrect use “since” and “for”
He has had hypertension FOR 10 years. (the period of time.) He has had
with present perfect
hypertension SINCE 1998. (the actual date.)
20. Passive voice – past participle
not used e.g. “He will be discharge Use the past participle “He will be discharged today.”
today.

21. wrong preposition e.g. “He “He had a pain IN his left side.” Use “in” when referring to a rash/scar/lesion
had a pain ON his left side.” etc. ON the skin. Everything else is IN the body.
 e.g. “The patient complained of…” “complaint” is a NOUN i.e. a complaint
22. wrong form of the word used “complained” is the past tense of the VERB to complain. NB loss is a NOUN
e.g “The patient complaint of…” and “lost” is the simple past or past participle of the VERB “to lose” e.g. “The
patient’s weight loss was 5 kgs.” OR “The patient lost 5 kgs.”

23. two independent clauses used Make your sentences more advanced in terms of structure so join the two
e.g. “The patient presented with clauses to make a relative clause e.g. “The patient presented with her
her mother. Her mother was mother who was concerned about…”
concerned about…”

24. an incomplete sentence as

Join the clause to an independent clause. “Although she was in pain she was
you’ve used a dependent clause by
able to perform her daily tasks.”
itself. E.g. “Although she was in
pain.”
Control of presentation features (spelling, punctuation and layout)
One of the criteria used to assess your writing in the OET exam is control of presentation features.
This criterion assesses the overall presentation of the letter and includes a lot of the features outside
the body of the letter including Letter format ,Punctuation, Capital letters and Spelling
Letter Spelling and Punctuation.
 Spelling : mistakes depend on how much it reduces comprehension and how common the word is.
 Capitalization (A ): When to use Capital Letters & Lower Case :
 Punctuation : Comma ( , ), Period ( .), Apostrophe ( ’ ), colon ( : ) , Semicolon ( ;),Hyphen (- ).

Your spelling and punctuation will also be assessed so when you review your work you should make
sure that your words are spelled correctly, and your punctuation is appropriate. In OET, you can use
any spelling convention, such as American, Australian or British. Whichever spelling convention you
choose to use, you must keep to this convention throughout your writing task.

* Take care with the placement of commas and full stops

Make sure that you are using enough full stops to separate distinct pieces of information, and using
enough commas to separate your ideas within sentences. As you read through your work, read your
letter to yourself in your head, pausing for commas and full stops, and check that it ‘sounds’ right to
you. If it doesn’t, look at changing your punctuation.
* Make sure there are enough – separating ideas into sentences
* Make sure there are not too many – keeping elements of the text meaningfully connected together
* Leave a blank line between paragraphs to show clearly the overall structure of the letter.
Remember to leave space (one blank line is ideal) between each paragraph, so that the assessor can
clearly see that you have sectioned your writing into a logical structure.
Each paragraph should address one main point in your letter.
* Don’t write on every other line – this does not assist the reader particularly
* Check for spelling mistakes and for spelling consistency through your writing (e.g.a patient’s name)
When checking your work, if you spot a word that looks like it is spelled incorrectly, but you cannot
remember how the word should be spelled, consider replacing it with a synonym that is easier for
you to spell. It is more important that you communicate effectively than that you use long words.
* Remember that many of the words and healthcare terms you write are also in the case notes –
check that the spelling you use is the same.
* Be consistent in your spelling: alternative spelling conventions (e.g., American or British English)
are acceptable as long as your use is consistent.
* Don’t use symbols as abbreviations in formal letters
* Avoid creating any negative impact on your reader through the presentation of the letter
* Use a clear layout to avoid any miscommunication
* Make sure poor handwriting does not confuse the reader over spelling and meaning
* Write legibly so the assessor can grade your response fairly using the set criteria
You need to write clearly and neatly, so that the assessor can easily read your handwriting. If your
writing is difficult to read, the assessor may not be able to assess your writing ability. If you
struggle with writing neatly and legibly, practise writing in English, and ask other people to read
what you have written.
Capitalization (A ): When to use Capital Letters & Lower Case :
 Names of people , Job titles , addresses and institution
 Titles when they precede the name of a person = The patient was seen by Doctor Smith.
 Brand name of a drug or registered trademark = Ritalin, Voltaren
 Some medical conditions are named after the person who discovered it. Parkinson’s disease
 Holidays, months, days of the week. But not seasons.
 The pronoun “I” must always be capitalized.
 The first word of a salutation and the first word of a complimentary close.

Comma : When to use ( , )

 a comma or a full colon after the name in salutations. Dear Mr. Hinges, common practice
 Use a comma for the closing words of any letter. Yours sincerely,
 In addresses if put the suburb & postcode on the same line. should be separated by a comma.
 With adverbial phrases such as unfortunately ,However, On today’s visit or Please note
 Conditional Sentences with (if). if clause is at the beginning of the sentence (in the conclusion ).
 Complex sentences with (In case, when , because ). if dependent clause is at the beginning .
 Commas to separate three or more words, phrases, or clauses written in a series.

Period : When to use ( . )

 At end of sentence = jimmy is a five years old.
 After single word = Hello.
 After number = Nov 2003.
 After abbreviation / titles such as Dr. , Mr. , Mrs. , Ms. But not Miss or Master

Apostrophe (’) : When to use (’)

 Use with possessive noun
 If singular noun added ’s = The nurse’s mask was blue.
 If plural noun added ’ = The nurses’ mask was blue.
 If singular noun ends with S added ’ = Mr Jones’ vital signs has change for the worse.
 Use with contraction = I’ve do it.
Colon ( : ) When to use (: )
 After the independent clause (complete sentence)
= Lately, I have had only one thing on my mind: graduation
 Before the word, phrase, sentence, quotation, or list of horizontal items they are introducing.
= Lately, I have had only one thing on my mind: papers, grades, and finals
 Use in salutation = Dear Dr. Roberts :

Semicolon ( ; ) When to use (;)

 Separate items in a list with each item has several bits .
= Mr jones has been coming to this clinic for past five year during which time he has had a
number of problems addressed: hypertension,(2004) ; osteoarthritis, (2005);GERD, (2008) .

Hyphen (- ): When to use ( - )

 When a numbers use as adjective (all work as single adjective ) = Ms. Grierson, a 58- year- old .
Note: When describing ages, phrases that function as adjectives will use hyphens
= jimmy is a five- year- old with a lot of energy.
While numbers as adjectives will not use hyphens.
= jimmy is a five years old.
 With numbers from 21- 99 = twenty-two .
 Indicate range of numbers = He suffered from chronic bronchitis from 2006- 2009 .
 With fraction = 2/3 two-thirds .
 before a proper compound noun = sister in-law / mother in-law
 before a proper compound adjective = Well-known , well-respected surgeon, self-image.
 To avoid confusion = re-check Ms. Grierson’s BP
 With prefixes = my ex-wife
Mistake Correction

1. ... a sever cold a severe cold

2. no capital letters Use capital letters with proper nouns e.g. names of people,
places etc. also official names like Work Cover, the Health
Department, the Pharmacy Guild etc. You DO NOT need to
use capital letters with diseases/medical conditions. Use
capital letters with trade names of medications e.g. “Panadol”
BUT not with generic names e.g. “paracetamol”

3. unnecessary use of capital letters Don’t use capital letters with medical conditions, body parts or
investigations BUT use capital letters with abbreviations e.g.
LFT.

4. Missing commas after adverbial phrases or Over the past five years, Mrs Jones has been responding well
clauses before the main clause (an introductory to treatment.
clause) .“On examination,…” “Two weeks later,…”
use a comma after these examples as they are
introductory clauses attached to the front of the
main sentence. A test to see if it is an
introductory clause is to take it away and if the
sentence still makes sense then it is not part of
the main sentence so it needs a comma after it.

e.g. Over the past five years Mrs Jones has been
responding well to treatment.

5.advise / advice “advise” is a verb: Rest was advised.

“advice” is an uncountable noun: The customer was given
some advice regarding pain relief.” (for pharmacists)
Letter organization (Letter Layout and format)

This worksheet will describe the characteristics of formal medical correspondence. To do this,
the letter has been broken up into 6 parts.

A Template
1. Address
----------------------------- Leave an empty line after the address.
2. Date. .. /.. /….
-----------------------------Leave an empty line after the date.
3. Salutation. Dear Dr …….,
-----------------------------Leave an empty line after the salutation.
4. Subject / Reference. Re: Mrs / Mr …… …. + D.O.B .. /.. /…. Or (aged 45)
-----------------------------Leave an empty line after reference.

5. Body. The information in the body should be divided into 3-4 paragraphs, as follows:

Body 1. Introduction : purpose of writing and chief complaint in brief

(small indent)

-----------------------------Leave an empty line after each paragraph.

Body 2. details relevant of Past medical/ relevant social particulars (e.g. the patient lives alone)
-----------------------------Leave an empty line after each paragraph.

Body 3. Current condition in detail or discharge plan /Any particular needs (e.g. a walking frame)
-----------------------------Leave an empty line after each paragraph.

Body 4. Conclusion. Concluding request specific to the task

-----------------------------Leave an empty line after each paragraph.

Note: Body paragraphs 2 & 3 can be interchanged depending on the task.

6. Closer.
(small indent) Yours sincerely,
-----------------------------Leave an empty line after Yours sincerely
(small indent) Doctor
Letter structure and grammar
Your letter should always begin by giving the date, the address and name or occupation of the
person you’re writing to, and a greeting to the person you’re writing to.
1. Address: The address gives the name and address of the person or facility to whom you are writing.
There are some basic conventions which need to be followed including:
 Capital letters for job titles, names & street names
 no punctuation (, / .) required between the address and separated by lines
 You can write Street as St (Avenue as Ave; Road as Rd etc.).
Dr. John Howard Lactation Consultant
1 Wickham Tce Breast Feeding Support Centre
Spring Hill 68 Main Street
QLD, 4010 Romaville
N.S.W, 2068

Leave an empty line before the date.

2. Date: The date should be placed at either the top left or top right of the letter or after address
and can be either written in full or as numbers as follows:
 21/07/16 // July 21, 2016 // 21st July, 2016
 The accepted format is 14 August 2018

Leave an empty line after the date.

3.Salutation: If the name of the person is included in the case notes then it should be used.
This can be followed/no by either a comma or full colon.
 Dear Dr Wilson // Dear Dr. Wilson, // Dear Dr. Wilson : Dear Dr. Wilson
In modern letters, you do not need a comma (,) after the salutation. (If you do use a comma,
then you must remember to use a comma after ‘Yours sincerely’ too.)
If the name of person is not mentioned and they are a non-medical person, then you can begin
with Sir/Madam as used in business correspondence or if they are a medical professional you
can use their job title Doctor/Nurse/Dentist etc
 Dear Sir/Madam , // Dear Doctor //Dear Nurse

Leave an empty line after the salutation.

4.Subject / Reference: The subject is a place where information such as the name & age of the pt can
be included. This can save you words in the body of the letter, but be careful not include too much
information here, and definitely nouns only (no articles, verbs, adjectives ,phrases or sentences).
Both Re & RE are acceptable.
 Re: Dylan Charles D.O.B.04/12/2010 // RE: Dylan Charles , 30 years of age

The basic rules regarding titles are as follows:

 Mr. is used for adult men, married or single
 Mrs. is used for married women including widows
 Ms. is used to refer to both married or unmarried women
 Miss is used for young girls or unmarried women
 Master is used for young boys, but is rare nowadays as it has become old fashioned.
It is still commonly used on an envelope, but not in the body of the letter.

Note: Both miss & master are not abbreviations so no punctuation is required.
Usually used above the address or after Re: but not on the body of the letter
Handy Tip 1: Definitely do not use titles with first names only, i.e Mr Thomas or Mrs.
Carol as this is not acceptable. See below for correct usage.
These titles can be used in the following ways - Thomas Hacker
 I am writing to refer Mr. Hacker (standard)
 I am writing to refer Mr. Thomas Hacker (very formal)
 I am writing to refer Thomas (informal and commonly used for children)
 I am writing to refer this patient (commonly used in the opening sentence if
patient's name has been mentioned above as in Re: Mr. Thomas Hacker)

When and how often should I use the patient's name in the letter?
The standard way is to write the patient's name in full below the opening saluation. Then, use
the patient's name once per paragraph as illustrated below ,after which you can use pronouns.
Also, be consistent in how you refer to the patient. Do not mix up your use of first names and
surnames in the letter as this will only confuse the reader.

Handy Tip: There is no need to write the patient's name out in full in the introduction if you have
stated it below the salutation i.e Re: Mrs. Carol Brady as it is very clear who you are writing
about. In such cases use "this patient" or title and surname "Mrs. Brady". If you do this you will
be following standard conventions.
Leave an empty line after reference.
5.Body: The information in the body of the letter should be divided into 3-4 paragraphs, with
the standard format for a referral letter being as follows:
Introduction: background information & purpose of writing or chief complaint in summary.
Paragraph 1: details of relevant of Past medical/social history.
Paragraph 2: In between visits.
Paragraph 3: Today visit, current condition, medication or discharge plan.
Conclusion: which if time permits, should be specific to the scenario in the case notes.

Introduction & conclusion : not write any details

Leave an empty line after each paragraph.

6.Closer: The closer is the final part of the letter and should be written one space below the last
line of the body. Only the first word in the closer should be capitalised and a comma may
following the last word or not.
 Yours sincerely,(standard)
 Yours sincerely (modern)

Leave an empty line after Yours sincerely

Sometimes you will need to write your own name. At other times, you may also need to write a
title given to you in the task (e.g. Doctor)
 Doctor

Note: Yours faithfully, is often recommended as a closer when you don't know the name of the
person to whom you are writing. However, in formal medical correspondence it is not advised as
it puts you in a subservient position.

Remember :Leave an empty line after

 In top and to left of letter
 Before and after date
 after the salutation.
 after the reference.
 after each paragraph
 after Yours sincerely
Body Paragraphs

Most referral letters contain 2 or 3 body paragraphs located between the introduction and the conclusion
Each of the paragraphs should have a main idea and all the sentences within the paragraphs must relate
to this main idea.

The length of the paragraphs will vary, but an approximate guideline to meet the required word length of
180 -200 words in OET is as follows:
• Introduction: 25 words
• Paragraph 1: Social and medical history = 45 words, Mainly present
• Paragraph 2: Previous visits history = 45 words, Mainly past
• Paragraph 3: Today visit, current condition, medication or discharge plan = 45 words, Mainly past
• Conclusion: = 25 words
Note: The word length is based on the body of the letter only.

Start counting from beginning of body …Thank you for seeing (not Yours sincerely)
 a/un /the counted as 1 word
 the date counted as 1 word
 UTI , URTI counted as 1 word

To reach to 180 -200 words

If note is short = write long sentence
 I would be grateful if you could manage her condition as you think appropriate.(14 words)
 please do not hesitate to contact me for any assistance you require regarding this patient.(15)
 for which she has been taking…. ,…..,………,……………..,…………….,……

If note is long = write short sentence

 Please note,... It is important to… Please ensure that… It is worth mentioning that..
 Your further management is highly appreciated (6 words)
 For any queries, please contact me. (6 words)
 Which have been managed accordingly
Writing notes

 Time is 45 minutes : 5 minutes reading and 40 minutes writing.

 Number of words should be 180-200 words +/- 10 words.
 Each paragraph should contain at least 2 sentences.
 The diseases are written in full and small letters if composed of one or two words, ex: diabetes
mellitus, gout.
 The diseases are written in abbreviation and capital letters if composed of three or more words,
ex: UTI, URTI.
 Investigations are written in abbreviation and capital letters, ex: CBC.
 Drugs are written capital for trade names, ex: Ventolin.
 Drugs are written small for generic names, ex: paracetamol.
 In short cases, use the long version of introductory and conclusion paragraphs, but in long cases,
 the short versions are used.
 Don’t forget to use capital letter after full stops and small letter after commas.
 Avoid too long sentences.
 Avoid mixing tenses in the same paragraph, except body 1.
 Use passive.
 Use formal terms, ex: inform tell, commence not start .
 Don’t write details in introductory and conclusion paragraphs.
 Use (an) for an X-ray and an MRI.
Introduction
Introduction Structure

Important tips on writing

It is important to provide a general context in the opening paragraph so that the reader immediately
knows who you are writing about and why you are writing.
In 1-2 long sentences provide the patient’s name, their hospital admission date, what health problem
he or she was admitted for, and what action is being taken now

Basically, the introductory sentences of the letter can contain the following:
1.Background information such as name, age, occupation, marital status and gender of the patient if
relevant and not mentioned in the subject line
2.A brief summary of the chief complaint, purpose of writing or your main concern

Mainly 2 sentences ( around 25 words) less details

Short template:
Thank you for seeing Mr Walter, a 30 years -old patient, who is presenting with features consistent
with gout. Your further management is highly appreciated. (25 words)
Thank you for seeing Mr Walter, a 30-year-old patient, who is presenting with symptoms and signs
suggestive of gout. Your further management is highly appreciated.

I am writing to refer you Ms Patrick, who is presenting with symptoms and signs suggestive of gout.
Your further management is highly appreciated.

Thank you for seeing Mr Walter, whose features are consistent with gout. Your further management is
highly appreciated.

Thank you for seeing Mrs Last, a 38-year-old physician, whose features are (consistent with) (suggestive
of) exam syndrome. Your further management is highly appreciated.

I am writing to refer Mr Last, an 80-year-old physician, who has recently developed examophobia. Your
further management would be highly appreciated.
Long template:
I am writing this letter to refer Mr Walter, a 30-year-old patient, who is presenting with signs and
symptoms suggestive of gout. I would be glad if you could manage his condition as you think
appropriate. (38 words)

I am writing this letter to refer you Ms. Patrick, a 30 years age sales person, who is presented at my
clinic today with symptoms and signs suggestive of gout. I would be grateful if you could manage his
condition as you think appropriate.
I am writing to refer you Ms Patrick, a 30-year-old patient, who has symptoms and signs suggestive of
gout. I would be grateful if you could manage his condition as you think appropriate.

I am writing to refer Mr Last, a 38-year-old physician, who is presenting with symptoms and signs
suggestive of exam syndrome. I would be grateful if you could manage his condition as you think
appropriate.

Other sentences that can be used in this paragraph:

 His condition is getting progressively worse.
 His condition is getting much better.
 His condition needs your further management.
Important grammar rules

The important patterns to learn are as follows:

Relative Clauses : ( who, whom, Whose ,which , that)

A relative clause is a useful sentence structure to use in the introduction

1. I am writing to refer this patient. Heis due to be discharged today. He has made a full recovery.

2. I am writing to refer this patient who is due to be discharged today after making a full recovery.

Appositives :

An appositive is a noun or a noun phrase that is placed after another noun to explain or identify it, and a
comma is required to separate these nouns. It has a very important use in the introductory sentence of
referral letters as in the example below.

1. I am writing to refer Mr. Barry Booth. He is 68 years old. He is a pensioner. He is a widower. He

requires dietary advice after undergoing heart surgery.

2. I am writing to refer Mr. Barry Booth, a 68-year-old widowed pensioner who requires dietary advice
after undergoing heart surgery.

Age hyphenated :

• it must be hyphenated when used before a noun such as man/woman.

• an article is required.

1. I am writing to refer Mr. Barry Booth, a 68-year-old widowed pensioner who requires dietary advice
after undergoing heart surgery.

Study Strategy
When writing introductions, find a style which you like and use it for all tasks.
However, take care to understand the basic grammar rules and always remember to include the chief
complaint, purpose of writing or your main concern.
Practice writing introductions using the sample case notes provided in your course.
Sample Introductions
Introduction Analysis
Dear Doctor, Does not include patient name as this is clearly
stated in the subject line
Re: Mr. Darren Walker
Uses relative clause and appositive sentence
I am writing to refer this patient, a 40 year old structures which demonstrate ability to use
married man with two sons aged 3 and 5, who complex sentences
requires screening for prostate cancer.
States purpose of writing clearly
Dear Dr Raymond, Includes shorter for a patient name as full
name stated in the subject line
Re: Dulcie Wood
DOB: 15/07/43 Uses appositive and relative clause sentence
structure which demonstrates ability to use
As arranged with your receptionist, I am referring complex sentences
Mrs. Wood, a66 year old widow who has been
demonstrating symptoms suggestive of heart States both purpose of writing and chief
arrhythmia. complaint

Includes reference to previous communication

Dear Doctor Normal, Sometimes a short and concise introduction is
all that is needed, and it can help keep your
Re: Catherine Walker
word length with required limits.
DOB 6.12.70
Thank you for your urgent attention to this patient Summarises chief complaint
who presented today with severe depression.
Dear Doctor, Summarises chief complaint and treatment and
current condition
Re. Mr John Pike,
I am writing to refer Mr Pike, a patient of mine for Includes relevant biographical detail: age,
habits & occupation
necessary emergency management of acute
peritonitis caused by perforation of peptic ulcers.
Expresses level of urgency
Mr Pike is forty years old and is a heavy smoker
and heavy drinker. He is a contractor in the
machinery industry and is suffering from stress.
Dear Doctor: Purpose of writing stated clearly in the subject
line
Re. Amina Ahmed (8years)
Summarises chief complaint
I am writing to refer Amina who is presenting with
signs and symptoms indicative of meningococcal Includes relevant biographical detail: family,
meningitis for urgent assessment and nationality & language concerns
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.
 Introduction
I am writing to request daily home visits by the
Blue Nurses to provide care and support for
this patient, a 61-year-old widow who lives on
her own.
Analysis
Does not include patient name as this is clearly
stated in the subject line
Uses relative clause and appositive sentence
structures which demonstrate ability to use
complex sentences

States purpose of writing clearly

I am writing to request aged care assistance for Uses appositive and relative clause sentence
Mr. O’Keefe, an 83-year-old man who is
recovering from a malignant melanoma in his
left shoulder.
I am writing with regard to Mr. O’Riley, a 53-
year-old man who was admitted the hospital
on the 2nd of September and diagnosed with
obstructive coronary artery disease. He
underwent a coronary artery bypass graft on
the 4th of September.
structure which demonstrates ability to use
complex sentences
States both purpose of writing and chief complaint
Includes shorter for a patient name as full name
stated in the subject line
Uses appositive and relative clause sentence
structure which demonstrates ability to use
complex sentences

Summarises chief complaint and treatment

I am writing to request a respite admission for Does not include patient name as this is clearly
this patient, a 41-year-old married mother of stated in the subject line Includes relevant
two who has been receiving personal care from biographical detail: age, marital status, mother
our organisation over the last two months.
Uses relative clause and appositive sentence
N.B. structures which demonstrate ability to use
Respite care is planned or emergency complex sentences
temporary care provided to caregivers of a
child or adult. States purpose of writing clearly and summarises
recent history
I am writing to inform you of a recent outbreak
of headlice at Mt Gravatt Primary School.
Although headlice spread easily and cause
several symptoms of itchiness and discomfort,
they are easy to diagnose and treat.
I am writing to refer this patient who was
admitted to our Coronary Care Unit ten days
ago with the diagnosis of myocardial infarction.
A cardiac artery bypass graft was done,
followed by post-operative treatment and
physiotherapy. Mr. Ali’s condition has now
stabilized and he is being discharged today.
I am writing to request further testing and
contraceptive advice for this patient, an 18-
year-old single woman who presented to our
clinic fora Pap test on 16th May.
Purpose of writing stated clearly in the subject line
Informs parents of main problem
Summarises symptoms and treatment briefly
Does not include patient name or age as this is
clearly stated in the subject line
States purpose of writing clearly and summarises
recent history
Summarises chief complaint and treatment and
current condition
Uses relative clause structure which demonstrate
ability to use complex sentences
Does not include patient name or age as this is
clearly stated in the subject line
States purpose of writing clearly
Uses relative clause and appositive structures
which demonstrate ability to use complex
sentences
Common errors
Incorrect Correct
Thank you for seeing Brendan 8 year old boy, who Thank you for seeing Brendan, an 8-year-old boy
is signs and symptoms demonstrated perhaps the who is demonstrating signs and symptoms
possibility of Rheumatoid arthritis suggestive of rheumatoid arthritis.

Explanation: Several errors in this introduction.

The important point is to follow the conventions
and patterns standard in introductions.
I am writing to refer the above named patient,
25 years old, who I worry that she may suffer
from ectopic pregnancy.
I am writing to refer the above named patient, a
25-year old woman who I suspect may be suffering
from ectopic pregnancy.

Explanation: As above. I am writing to refer this 25-year-old woman who

I am writing to refer Miss. Cathy Jones, a 25-
year-old single receptionist who is presenting
with signs and symptoms of ectopic pregnancy
to you for urgent assessment.
Explanation: ..to you should be omitted as it is
too far apart from the verb it is connect to refer
presented with signs and symptoms suggestive of
ectopic pregnancy.
I am writing to refer Miss. Cathy Jones, a 25-year-
old single receptionist who is presenting with signs
and symptoms of ectopic pregnancy for urgent
assessment.

Mr. James Warden is a patient of mine. I am I am writing to refer Mr. James Warden, a patient
writing to refer him to you for further of mine to you for further assessment and
assessment and management of his bilateral management of his bilateral inguinal swelling.
inguinal swelling.
Explanation: No grammatical errors but does not
display the complexity required to earn a B
grade or higher.

I am writing with regard to this 81 year-old

widowed patient presents with a ten-year-
history of dementia which has become worse in
recent months.
Explanation: Requires relative clause structure
with who
I am writing with regard to this 81-year-old
widowed patient who presents with a ten-year-
history of dementia which has become worse in
recent months.
Common errors
Incorrect
I am writing to refer Mr Adrian Lamp to you, an
61-year-old widower. He is due to be discharged
today. He has made a full recovery from chest
congestion.
Explanation: No grammatical errors, but it lacks
sophistication in the use of simple sentences.
Also, it repeats the patient name in full which is
not necessary and repetitive since it was written
directly above in the subject line
Thank you for admitting Mrs. Saunders, an 80-
year-old dementia patient, requires respite care
for a period of two months.
Explanation: Relative pronoun required.
I am writing in regards of Annette Mac Namara ,
single, age pensioner, requesting your assistance
when she discharged from this hospital today.
Explanation: Several errors in terms of sentence
structure and grammar.
I am writing to refer Mrs Atherton, a 77 year old
woman who is a resident at the Sandy Beach
Retirement Village, who needs urgent admission
to your hospital due to chest pain.
Explanation: Incorrect sentence structure with
two relative clauses.
I am writing to refer Cooper a 12-year-old boy,
who is a year 6 student at Wellers Hill State
School.
Explanation: Two errors 1. Use first name when
referring to a child. 2. Incorrect comma
Correct
I am writing to refer this patient to you, a 61-year-
old widower who is due to be discharged today
after making a full recovery from chest congestion..
Thank you for admitting Mrs. Saunders, an 80 year-
old dementia patient who requires respite care for
a period of two months.
I am writing in regards of Annette Mac Namara , a
single age pensioner who will require your
assistance when she discharges from hospital
today. Or
I am writing to request assistance for Annette Mac
Namara , a single age pensioner who is due to be
discharged from this hospital today
I am writing to refer Mrs Atherton, a 77-year-old
woman who is a resident at the Sandy Beach
Retirement Village. She needs urgent admission to
your hospital due to chest pain. Or
I am writing to refer Mrs Atherton, a 77-year-old
female resident at the Sandy Beach Retirement
Village who needs urgent admission to your
hospital due to chest pain.
I am writing to refer Aiden, a 12-year-old boy who
is a year 6 student at Wellers Hill State Please note,
he has a prosthetic heart valve. (emphasis)
Common mistakes

Mr. Langer is an only child. Alfie is an only child.

Explanation: Mr. is only used for adult

men, so if the patient is a child you should
use their first name.
Thank you for seeing my patient, Master Thank you for seeing my patient, Alfie
Alfie Langer, a 7 year old boy. Langer, a 7 year old boy.

Explanation: Master is somewhat old

fashioned and does not sound "familiar" if
used in the body of the letter.
Mr. Peter, a 23 year old young man,
presented at my surgery today
complaining of painful wisdom teeth.
Mr. Holmes, a 23 year old young man,
presented at my surgery today
complaining of painful wisdom teeth.

Explanation: You can not use titles with

first names only ,here use family name.
I am writing to refer Miss. Green for I am writing to refer Miss Green for
surgical assessment. surgical assessment.

Explanation: Miss is not an abbreviation

so no punctuation required.
Dear Dr.,I am writing this letter.... Dear Doctor, I am writing this letter....

Explanation: Do not use short forms

without the surname of the person
Middle paragraphs structure and important grammar rules

Paragraph Structure

The middle paragraphs will contain details of relevant medical and social history from the case notes.
A chronological sequence for the paragraphs helps the reader follow the patient’s situation
outline the patient’s condition upon admission, tests and treatment protocols they have undergone
while in your care, including information on their progress, and finally advise the reader on how he or
she can assist the patient in treating or managing the condition post-discharge.

Paragraph must contain:

Body 1 : Social and medical history, 45 words

 Mainly present, you can mixing tenses in this paragraph.
 Use compound and complex sentences
 Use Adverbial phrases : Regarding her medical history, Please note, ….

Body 2: Previous visits, 45 words

 Mainly past ,you can’t mixing tenses in this paragraph.
 Use compound and complex sentences
 Use Adverbial phrases : On 15/01/2018, ……..
 Use Connectors
 Use conjunction …….; thus … and ….therefore,……. , but …..later on, ...
 Use Active and passive sentences
 Use Punctuations marks
 Chronologically arranged

Body 3: Final visit (today), 45 words

 Mainly past, you can’t mixing tenses in this paragraph.
 Use compound and complex sentences
 Use Adverbial phrases : Today, Ms.… came reporting that (to) ... Thus, ..
Body 1: Social and Medical History (Around 45 words) Mainly present
Short template:
Ms Adams is married with three children. However she does not smoke, she is a heavy drinker.
Regarding her medical history, she is ……… . Please note, her father had ………. .
Mrs Last is married with two children. Regarding (In terms of ) her medical history, she suffers from
vocabularies deficiency for which she has been taking English courses. Please note, ……………….(26)
Mr Last is widowed with two children. He has a medical history of (His past medical history reveals that)
Mr. Last is single. His past medical history is unremarkable apart from (disease) which has been
managed accordingly.

Long template:
Mrs Last is married with two children. Her medical records reveal that she has a long history of (disease)
for which she has been taking(medication). It is worth mentioning that the patient has an allergy to (is
allergic to). (34)
Body 2: Previous visits (Around 45 words) Mainly past
On 07/03/2013, the patient presented complaining of ---------. Consequently, blood tests were ordered
which revealed--------. A month later, she attended the clinic for ---------. Later on,------------- (other visits
but not the last), she …………. ..
On 15/01/2018, Mr Last attended my surgery with (presented with) a two-day history of… ; thus, he ….
One month later, he developed ……and ….Therefore, he was prescribed … , but he noticed …. Later on, ..

You should use them properly:

 Connectors
 Compound and complex sentences
 Active and passive sentences
 Punctuations marks
 Chronologically arranged

Body 3: Today Visit (Around 45 words) Mainly past

In addition to the previous notes: Select the relevant data which would be important for the
person you are writing to.
Today, the patient came reporting that (to) ----------. Thus,------------------.
Today, Mrs Last complained of ... Therefore, ...
Important grammar rules

A good paragraph will contain 3 main elements

1.A Topic Sentence which introduces the reader to the main idea of the paragraph. In many cases it will
identify and/or summarise an area of concern regarding the patient. Quite often it is written in original
words rather than from words in the case notes.
2.Supporting sentences which may contain the detail regarding patient history, descriptions of
symptoms, significant aspects from the treatment record, causes and effects, trends and so on. Quite
often this information can be taken directly from the case notes, and written as full sentences. However,
you will need to paraphrase the information into your own words. This includes:
• Changing verbs to nouns: complain=complaint
• Changing adjectives to nouns: lethargic=lethargy
• Using synonyms

3.Signal words link sentences together so that the information flows smoothly and is easy to read.
Common signal words which can help you present information clearly and logically include:
• Time: At that time, On review today, On consultation today, Recently, Over the past 3 weeks...., Two
weeks later, On her next visit, During, Since that time, Initial examination..., On 19/08/10...
• Location: During hospitalisation, Initial examination at my clinic revealed...,On examination....
• More information: In addition, Moreover, Also, Apart from this..
• Contrast: However, Despite, Although
• Result: Therefore, Consequently, As a result, For this reason...
• Emphasis: Please note, May I remind you, My main concern is...., What concerns me most is.....
• Sympathy: Unfortunately, Regrettably, Fortunately,
• Subject: In terms of her social history..., With regard to her medication....,Based on the blood test
results....., Regarding her medical history....., Her dental history shows..., The risk factors include.....,
Treatment to date includes...
• Advice: It is important to..., I recommend that you....., Please ensure that....
• Chronology: Firstly, Secondly, Finall
Sample Paragraphs
Case Notes
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
Paragraphs Analysis
I am writing to refer Amina who is Topic is In this letter, the writer uses
presenting with signs and the introduction to include both the
symptoms of meningococcal chief complaint and the relevant
meningitis for urgent assessment social factors
and management. She is the
first child of a family of 5, which Supporting sentences transform case
includes her parents and two notes into complete sentences
younger siblings.
They are immigrants from Somalia,
though she and her father
understand English.

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.
09/10/10 Initially, accompanied by her topic sentence, is introduced with the
Subjective parents, she presented to me on phrase: Initially...she presented to me
Fever, runny nose, mild cough, loss of 9.10.10 with complaints of fever, on 9.10.10..
Appetite Unable to attend school runny nose, cough and loss of
Objective appetite. She was febrile with Supporting sentences transform
Pulse 85/min a temperature of 39.4 and a pulse case notes into complete sentences
Temperature 39.4 rate of 85 beats per minute, but Second visit is only briefly summarised
No rash there was no rash or neck stiffness.
No neck stiffness However, her condition continued Signal word shows contrast and
CVS, RS & abdo – normal to deteriorate over the next three cause and effect
Assessment days as the fever could not ○ Initially,
Viral infection be controlled by antipyretics. ○ However,
Management Therefore, blood and urine tests ○ Therefore,
Keep home from school were ordered.
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
 Regrettably, today Amina became This paragraph explains the
14/10/10 lethargic and listless. She vomited current condition is detail
Subjective twice last night and had been Supporting sentences expand the
Both parents very concerned having severe headaches. case notes into complete
Reported Amina lethargic and listless On examination, she was sentences, note the use of verbs,
Vomited twice last night and headaches severely febrile with a temperature articles and conjunctions (and)
Worse of 40.2 and a pulse rate of 110 Signal word shows empathy
beats per minute. There was ○ Regrettably,
Objective macula-papular rash over the ○ On examination,
FBC- WBC(18000) and left shift legs and neck stiffness was
Urinary Function Report Normal present. Blood test showed
Temperature 40.2C leucocytosis with a shift to the
Pulse 110/min left..
Macula-papular rash over legs
Neck Stiffness+
Example 2
Case Notes Paragraphs Analysis
Medical History Initially, she presented to me on The topic sentence is begins with
Thyroidism diagnosed Feb 07 21/2/10, complaining of inflamed, the first consultation
High blood pressure June 09 sticky and weeping eyes. Both her Supporting sentences transform
Hip replacement July 09 eyes were reddish with watery case notes into complete sentences
Medications – thyroxine 1mg daily, discharge. However, her right eye Includes both medical history and
Atacand 4mg daily, Fosamax 10mg daily was worse than the left eye. initial consultation
No known allergies Therefore, she was prescribed
21.02.10 chlorisig drops 4 hourly. In terms of Signal words express a time line,
Subjective her medical history, she has had contrast and cause and effect.
Complains of inflamed, sticky and thyroidism for 3 years, high blood ○ Initially,
weeping eyes. pressure for 1 year and a hip ○ However,
Objective replacement was done in 2005. Her ○ Therefore,....
BP 135 /75 P 74 current medications are Thyroxin 1 ○ In terms of...
Both eyes – red, watery discharge right mg, Atacand 4 mg and Fosamax 10 ○..current
eye worse than left mg daily.
She has no known allergies.
03.03.10
Subjective On review 2 weeks later, she had Topic sentence is introduced with
No improvement to eyes, blurred vision made no improvement. In addition, the phrase: On review 2 weeks later
Objective she had blurred vision with Explains medication details clearly
Odema eye lids ++ odematous eye lids and in complete sentences
Marked conjunctival congestion conjunctival conjestion.Therefore, Signal words continue time line
Plan chloramphenicol was prescribed ○..Two weeks later,
Chloramphenicol 0.5% sterile 1 drop TID 0.5% one drop three times daily ○..In addition,
Bion Tears 1 drop each eye 4 hrly and Bion tears one drop 4 hourly. A ○..Therefore,
Review 2 weeks review was schedule after 2 weeks.

05.06.10
Subjective
Accompanied by husband. Very Unfortunately, today she was Summarises medical condition
distressed. Has lost most sight in both accompanied by her husband with clearly and concisely with the
eyes –can make out light or dark shapes complaints of impaired vision in expression "vision Impairment"
but unable to read or watch TV. both eyes and an inability to read Supporting sentences expand
Objective books or watch television. There case notes into formal sentences
Marked oedema upper and lower lids was oedema in both eyelids with Signal words add sympathy
White sticky discharge Unable to read white discharge. She could not ○..Unfortunately,
eye chart read the eye ○..wink
Plan
Refer immediately Emergency Dept,
Royal Melbourne Eye Hospital.
Husband will drive to hospital
Example 3
Case Notes
Diagnosis
Right partial rotator cuff tear
Presented to Mater hospital with pain
and weakness in the right shoulder,
especially when lifting arm overhead.
Descending stairs at home and slipped,
falling onto outstretched arm. Xray and
MRI showed a partial rotator cuff tear.
Orthopaedic surgeon discussed surgery.
Patient prefers to try non-surgical
treatment.
Date of admission: 30-10-2008
Date of discharge: 01-11-2008
Treatment
Ibuprofen orally QID
Cortisone injections
Daily physiotherapy
Medical History
Diabetes Mellitus Type 2
Metformin 500mg mane
Nursing Care Needs
Needs blood glucose level monitoring 4
hourly
May be elevated because of cortisone
Needs assistance with shower and
housework
Orthopaedic review on 19th November
Social Background
Marital status: Widow. No children.
Lives alone
Next of kin: Megan Mack (Niece) Niece
lives with husband in Sydney who works
as software engineer for Google Australia.
Sister died recently. No other relatives.
Paragraphs
Ms. Harwood was admitted to our
hospital on the 30th of October
with a diagnosis of right rotator
cuff tear following a fall while
descending stairs. Therefore,
surgery has been suggested,
however, she prefers non-surgical
treatment. She has received
ibuprofen and cortisone as
prescribed and also daily visits by a
physiotherapist.
In terms of her medical history, she
suffers from type 2 diabetes
mellitus for which she is taking
metformine 500mg. However,
following her discharge, she will
need a regular monitoring on the
blood glucose level which may
become elevated due to
administration of cortisone during
hospitalisation. She will also
require assistance in showering
and home help. As well as this, she
needs to review her condition with
an orthopaedic surgeon on the
19th of November.
Ms. Harwood lives alone and has
no children. Her next of kin is her
niece, Megan Mack who lives in
Sydney. Regrettably, she has no
relatives or friends to support her.
Analysis
Topic sentence is introduced with the
phrase: Ms. Harwood was admitted to
our hospital on....
Supporting sentences transform case
notes into complete sentences
Signal words express cause and effect
and express contrast
○ Therefore,
○ However,
Topic sentence is introduced with the
phrase: In terms of medical history,
Supporting sentences transform case
notes into complete sentences
Signal words
○ contrast = However,
○ Reason = due to
○ connect ideas = also
○ connect ideas = As well as this,
There is no topic sentence, but the
main idea of social history is clear
Supporting sentences expand the case
notes into complete sentences, note
the use of verbs, articles and
conjunctions (and)
Signal word shows empathy
○ Regrettably,
 Example 4
Birth History
Normal vaginal birth at term Birth weight:
3400gm Apgar score at 5min: 9 No
antenatal or postnatal complications
Feeding
Breast fed for first 3 weeks after birth.
Baby became unsettled during heat wave
at Christmas.
Mother got sick and had a fever for a few
days. Mother-in-law came to visit and
advised changing baby to formula feeds.
Mother-in-law advised extra powder in
formula feeds to improve weight gain.
Mother-in-law says her son (Ray Charles)
also had feeding problems and difficulty
gaining weight as a baby.
Mother says she is worried she does not
have enough breast milk and now gives
extra formula feeds as well as breast
feeding. She wishes she could breast feed
properly as she believes it would be the
best thing for her son. He hasn’t taken to
the bottle.
15/01/10
Subjective
Mother and baby attended for routine 6
week check-up. Mother says she is
concerned about constipation: once every
three days, hard stool. Mother is asking
about stool softener or prune juice for
baby.
Objective
Reflexes normal Lethargic
No abdominal tenderness
Heart Rate: 174 Respirations: 56
Temperature: 37.1 Weight: 4200gms
3 wet nappies in last 24 hours.
Urine dark.
Assessment
Mild constipation and dehydration
The patient was born via vaginal
birth at term with a birth weight of
3400 grams. During a heatwave at
Christmas, the baby became
unsettled, due to lack of fluids.
When the mother became sick for
a few days, her mother-in-law
visited to help out but has advised
her to change to formula feeds and
to put more powder in the bottle
to improve weight gain. However,
the mother believes that breast
milk is the best for her baby and
would like to breast feed full-time
but is worried that she doesn’t
have enough breast milk for the
baby. Therefore, she has been
giving extra formula feeds to the
baby.
At the 6 week check-up, the baby’s Topic sentence is introduced with
weight is 4200 grams and his vital the phrase: At the 6 week check up,
signs are in normal limits.
However, the baby is suffering
from mild constipation,
dehydration and lethargy.
The topic sentence is begins with the
baby's birth.
Supporting sentences transform case
notes into complete sentences
Displays understanding of the long
case notes by summarising the main
idea. Explains conflicting views of
mother and mother-in-law.
Signal words express,
○ a time line = During a heatwave
○ a time line = When...
○ contrast = However,
○ cause and effect = Therefore,....
Focuses on objective information
and final assessment. Omits less
relevant detail.
Summarises objective details
concisely into "vital signs in normal
limits"
Paraphrases adjectives into nouns
i.e lethargic=lethargy
Plan
Increase breast feeds.
Refer to breast feeding support service.
Check formula is correctly prepared.
If continuing formula feeds, advise to
supplement with water (boiled and cooled).
Advise on keeping baby cool in hot weather.
Return for review in 48 hours.
Could you please support and
advise the mother regarding
breastfeeding and correct
preparation of formula feeds if
required. In addition, advice on
how to keep the baby cool in hot
weather is necessary. Please note,
the patient is due for review on
17/01/2010.
Topic sentence is a request of support
Supporting sentences expand case
notes into formal sentences
Signal words add cohesion
○ In addition,
○ Please note,
Conclusions structure and important grammar rules

Final paragraph: Conclusion

The final paragraph should summarise your request (why you are referring this patient).

Conclusion or final paragraph should be standard in structure:

• It should be based on the task question
• It may contain one or two of the following points:
○ a polite request of action required
○ a thank you for ongoing support
○ an offer of future assistance if required (useful if you choose to omit some details from the case notes)

It is useful to be familiar with some standard patterns so that you are able to conclude your letter
confidently, quickly and most importantly, accurately. However, some degree of originality will impress
the assessors. Therefore, where possible try to ensure that your conclusion is related to your task and not
simply a memorised ending.

Short template:
In view of the above, I am referring this patient for further management of her condition. For further
queries, contact me. (21 words)

I am referring this patient to you for further care and investigations. For further queries, For any
queries, please contact me.

My provisional diagnosis is Therefore, I am referring this patient for further management. For any
queries, please contact me.
In view of the above, I am referring this patient for further management of his/her condition. For any
queries, please contact me.
Long template:
My provisional diagnosis is gout. Therefore, I am referring this patient for further management of her
condition. For further queries, please do not hesitate to contact me. (27 words)

My provisional diagnosis is ... Thus, (Or Therefore,) I am referring this patient for further management
If you have any queries, please don't hesitate to contact me.
My provisional diagnosis is…. I am therefore referring this patient for further management and possible
(service). Should there be any queries, please do not hesitate to contact me.
Handy hint

When describing the chief complaint or your diagnosis, try to use different words or sentence structure to
what you have said in the introduction.

Important grammar rules :

Modal Verbs :

Some modal verbs & the verb hope are used to convey politeness and commonly used for polite requests
in the conclusion of formal letters. Could you.. I would be grateful if.. I hope you…..

Conditional Sentences:

These sentences are also frequently used in the conclusion of a referral letter
It would be greatly appreciated if … Please don’t hesitate to call me if….
Some used expressions and sentences:

 Mrs .. Is a widowed woman with 4 children, but she lives alone.

 Mrs … is a single woman whose medical history is unremarkable except for allergy to certain drugs as
 Mr …. Is a single man who is known to be smoker.
 Ms … is a single non-smoker patient who has history of ….
 Ms …. Is a single woman who used to live with her boyfriend with no family in Australia. (Nov. 2014)
 She does not smoke nor drink.
 However he does not smoke, he is a heavy drinker.
 He is a heavy smoker and he drinks as well.
 She has osteoarthritis along with aortic valve replacement. (March 2015)
 The patient was referred upon his request. (May 2014)
 As a result, he was commenced on …..
 Adherence to Pulmicort is reinforced. (October 2014)
 Eventually, she agreed on the referral to a psychiatrist. (November 2014)
 Please informing about the possibility of surgery is highly appreciated. (July 2014)
 She has osteoporosis and dementia, for which has been prescribed …..
 She was non compliant to her treatment.
 Your advice on the duties that can be done is highly appreciated. (June 2015)
 But unfortunately his condition achieved no improvement.
 Fortunately, the asthma was controlled by ….
 The patient regrettably presented with worsening symptoms.
 His medical history is unremarkable apart from being overweight.
 It is worth mentioning that ….
 The patient presented complaining of ….
 The patient came reporting that …..
 The patient attended the clinic for …..
 Remember to use the joining words as:
; therefore, ; however, ; hence , ; consequently ,
; in addition, ; then, ; thus , ; moreover ,
 Compare the Conclusions patterns
Informal Polite
I want you to see him as early as
possible and advise him on
further management.
I will be pleased if you can
examine, diagnose and treat the
patient as you feel appropriate.
Please see him as early as
possible and advise him on further
management.(this sounds like an
order so should not be used)
Please examine, diagnose and
treat the patient as you feel
appropriate.
More polite
I would appreciate it if you could see him as
early as possible and advise him on further
management.
It would be greatly appreciated if you could
see him as early as possible and advise him on
further management. (passive and most
polite)

Can you take over her care for Please take over her care for I would be grateful if you could examine,
appropriate treatment. appropriate treatment. diagnose and treat the patient as you feel
appropriate. (active)
Explanation: These sentences are
Explanation: These sentences are acceptable in written English, but I would appreciate it if you could examine,
fine in spoken English, but not can sound quite direct. diagnose and treat the patient as you feel
suitable for formal writing. Can appropriate. (active)
and will are considered less
polite than could and would. I would appreciate it if you could take over
her care for appropriate treatment.

I would be grateful if you could

take over her care for appropriate
treatment.

Explanation: These sentences are the

most suitable for concluding requests in
formal letters.
 Informal Polite More polite
Can you examine and treat the Please examine and treat the patient Could you please examine and treat the
patient as you feel appropriate as you feel appropriate. patient as you feel appropriate

I will be pleased if you can examine, Please examine, diagnose and treat I would be grateful if you could examine,
diagnose and treat the patient as you the patient as you feel appropriate. diagnose and treat the patient as you feel
feel appropriate. appropriate. (active)

Can you arrange someone to help this Please arrange someone to help this I would appreciate it if you could examine,
family and provide proper medical family and provide proper medical diagnose and treat the patient as you feel
support. support. appropriate. (active)

It would be greatly appreciated if you

Explanation:
These sentences are fine in spoken
English, but not suitable for formal
writing. Canand willare considered
less polite than couldand would.
Explanation:
These sentences are acceptable in
written English, but can sound quite
direct.
Could examine, diagnose and treat the
patient as you feel appropriate. (passive
and most polite)
I hope you can arrange someone to help
this family and provide proper medical
support.

Explanation:
These sentences are the most suitable for
concluding requests in formal letters.
Conditional Sentences:
These sentences are also frequently used in the conclusion of a referral letter and the rules are as
follows:

Use a comma when the if clause is at the Don’t use a comma when the if clause is at the
beginning of the sentence. end of the sentence.
if you could take over her ongoing care, it would It would be greatly appreciated if you could take
be greatly appreciated. over her ongoing care.

If you have any further questions regarding this Please don’t hesitate to call me if you have any
patient, please don’t hesitate to call me. further questions regarding this patient.

If you require any more information, please Please don't hesitate to contact me if you require
any more information.(active)
don't hesitate to contact me.(active)
Please don't hesitate to contact me if any more
If any more information is required, please don't
information is required.(passive)
hesitate to contact me.(passive)

Should you have any further queries, please Please don't hesitate to contact me should you
don't hesitate to contact me. have any further queries.

Note: Sometimes if is omitted from a conditional

sentence. In full the sentence means:
If you should have any further questions
regarding this patient, please don’t hesitate to
call me.
Sample Conclusions
Case Notes
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
Assessment
Bilateral inguinal hernia
Advised patient you want to refer him to
a surgeon. He agreed but says he wants
a local anaesthetic as a friend advised
him he will have less after effects than
with general anaesthetic.
Writing Task
Write a letter addressed to Dr. Glynn
Howard, 249 Wickham Tce, Brisbane,
4001 explaining the patient's current
condition.
Conclusion
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
Based on my provisional diagnosis
of a bilateral inguinal hernia, I
would like to refer him for surgery
as early as possible.
Please note, that Mr Warden
wishes to have the surgery under
local anaesthesia.
Yours sincerely,
Dr X (GP)Yours sincerely,
Analysis
Uses information from the writing
task to formulate conclusion
Refers back to what was said in
the body of the letter: In view of
the above signs and symptoms
Contains a polite request and
maintains polite tone through the
use of modal verb: would
Includes suspected diagnosis and
level of urgency
Uses information from the final
consultation and writing task to
formulate conclusion
Uses sophisticated vocabulary
and expression: Based on my
provisional diagnosis of
Adds extra information specific to
the task with the expression:
Please note,
Plan
Suspected angina - refer to cardiologist
for cardiovascular assessment.
Writing Task
Write a referral letter to cardiologist Dr.
Ken Wilson. Suite 5, Greenslopes
Hospital Medical Centre, Brisbane 4121.
Assessment
Depression. Severe. ?Bi polar
Needs urgent treatment
Called to husband
Writing Task
Write a referral letter to psychiatrist
Dr. Abe Normal Brampston St, Mt
Gravatt ,4121,QLD.
Assessment
Diagnosed peritonitis with perforation
Writing Task
Refer urgently to the Emergency
Department Admitting Doctor
I believe he needs cardiovascular
investigations in order to rule out
angina pectoris. I would appreciate
it if you could see him as early as
possible and advise him on further
management.
Yours sincerely
Dr Z
I believe that Catherine needs an
urgent psychiatric consultation
regarding her acute episode of
depression and I would appreciate
it if you could take over her care
for appropriate treatment.
Yours sincerely,
Dr X (GP)
I would appreciate your
assessment and emergency
management of this patient’s
condition. If you need further
information, please feel free to
contact me.
Yours sincerely,
Dr X
Uses information from the writing
task to formulate conclusion
Maintains polite tone through the
use of modal verbs would & could
Uses appropriate expression: in
order to rule out
Summarises chief complaint in
original language
Maintains polite tone through the
use of modal verbs would & could
Uses polite request for on going
Care
Note, sometimes a brief
conclusion is all that is required....
or all that you will have time for!
Although it is a memorised phrase
to some degree, it is
grammatically correct, concise,
direct and contains a level of
urgency
Maintains polite tone through the
use of modal verb would
Contains an offer of future
Support
Example 2
Case Notes
Writing Task
MrO’Riley has requested advice on low
fat dietary guidelines and healthy simple
recipes. Write a letter to the Community
Information Section of the Heart
Foundation, Gregory Terrace, Brisbane
on the patient's behalf. Use the relevant
case notes to explain MrO’Riley’s
situation and the information he needs.
Include Medical History, Body Mass
Index and lifestyle. Information should
be sent to his home address
Writing Task
Using the information in the case notes,
write a letter to The Director, Community
Child Health Service, 15 Pauline Street,
Kuraby, requesting follow-up of this
family
Writing Task
Write a letter for the admitting doctor of
the Medivale Hospital Emergency
Department. Give the recent history of
events and also the patient’s past
medical history and condition.
Writing Task
Write a referral letter to the Dr Jane
Thompson, Medical Practitioner at the
North Fitzroy General Practice,
requesting assessment of your patient'
condition. Give the recent history of
events and also the patient’s past
medical history and condition.
Conclusion
In order to maintain a good health
condition, Mr. O’Riley has
requested advice on low fat dietary
guidelines and healthy simple
recipes. It would be greatly
appreciated if you could send the
above mentioned information to
Mr. O’Riley at his home address,
9476 Old Dam Road, Goondiwindi,
QLD, 4390.
Yours sincerely,
I hope you will be able to arrange
someone who can help this family
and provide proper medical
support. Please do not hesitate to
contact me if you require any
further information about this
family.
Yours sincerely,
I would appreciate your
assessment and emergency
management of this patient’s
condition.
Yours sincerely,
It would be greatly appreciated if
you could assess the patient's
condition and treat as you feel
appropriate
Yours sincerely,
Analysis
Uses information from the writing task
to formulate conclusion
Contains a polite request
Maintains polite tone through the use
of modal verbs would and could
Contains information specific to the
task
Uses information from the writing task
to formulate conclusion
Contains a request using the polite
expression: I hope you will be able to..
Contains information specific to the
task Offers future assistance
Uses information from the writing task
to formulate conclusion
Maintains polite tone through the use
of modal verb would
Maintains level of urgency appropriate
to the situation
Contains a very polite request using
conditional "if" plus passive form
Polite tone through the use of modal
verbs would & could
Note, sometimes a brief conclusion is
all that is required,.... or all that you
will have time for! Although it is a
memorised phrase, it is grammatically
correct, concise and direct.
Discharge Plan
Organise social worker and Meals on
Wheels. (niece will visit at weekend to
help with housework and shopping)
Stitches to be removed and situation to
be reviewed at Out Patient Department
appointment -10.30 am 31-05-09Writing
Task Using the information in the case
notes, write a letter to the Director, Blue
Nursing Service, 207 Sydney Street, West
End.
It would be greatly appreciated if
you could do daily home visits and
provide support and reassurance
for Mrs. Butler. In addition, please
organize Meals on Wheels and a
social worker for home help.
Please note, the patient has an
appointment at the Out Patient
Department at 10.30 am 31-05-09
for the removal of stitches . Thank
you for your ongoing care. Yours
sincerely,
This is a long conclusion, but
incorporates discharge plan into the
conclusion which is an effective
strategy
Emphasises a future appointment
Maintains polite tone through the use
of modal verb would & could
Contains a polite thank
Common errors
Incorrect Correct
I would very much appreciated your attention I would very much appreciate your attention regarding
regarding further management of Mr. further management of Mr. Henderson.(active)
Henderson. Your attention regarding further management of Mr.
Henderson would be very much appreciated.(passive)
Explanation: Incorrect grammar, see above

If you have any query, please do not If you have any queries, please do not hesitate to contact
hesitate to contact me. me.
Explanation: Use plural form of query

I will appreciate your further assessment I would appreciate your further assessment and
and management management.
Explanation: Polite form "would" required

In view of the above findings I believe he In view of the above findings I believe he needs an
needs an abdominal CT scan. Therefore, I abdominal CT scan. Therefore, I would greatly
will greatly appreciate your further appreciate your further assessment for Mr Backo
assessment for Mr Backo.

Explanation: Polite form "would" required

instead of would

Kindly investigate this child and do the I would appreciate it if you could investigate this child’s
needful. If you need any more information condition and do the necessary management. If you
regarding her situation, please try to require anymore information, please do not hesitate to
contact me without any hesitation. contact me.
Explanation: Several errors here. Basically it
is important that the standard patterns and
style conventions are followed in conclusions.
Based on above history and physical
findings, I suspect she may have a ruptured
rupt. I will appreciate if you would offer
your expert assessment to this lady. Please
keep me informed of the outcome.
Based on the above history and physical findings, I
suspect she may have a ruptured ectopic pregnancy. I
would appreciate it if you could offer your expert
assessment to this lady. Please keep me informed of the
outcome.

Explanation: Two errors: 1. Incorrect use of

modal 2. Omission of the definite article the

I would appreciate it if you could review and arrange a

Thanks to review and arrange a home visit
home visit for this patient. If you have any further
for this patient, if you have any further
questions, please do not hesitate to contact me.
questions, please be free to ask me.
It would be appreciated if you could review and arrange a
Explanation: As above, several errors here.
home visit for this patient. Please do not hesitate to
The style is casual and therefore an
contact me if you have any further questions.
inappropriate way to conclude a letter

I would be appreciated if you could take It would be appreciated if you could take over the care of
over the care of this patient. this patient. (passive verb)

I would be appreciative if you could take over the care of

would be appreciative if you could take over the care of
Explanation: Incorrect grammar this patient.(be + adjective)

I would appreciate it if you could take over the care of

this patient. (active verb)

Tip
As with introductions, when writing conclusions, find a style and pattern which you are confident
with and use it. However, take care to understand the basic grammar rules and always remember to
respond to the task question. Practice writing conclusions using the sample case notes provided in
your course.
Closer and signature

Leave a space between the last line of the conclusion and the closer.
The closer should be followed by a comma.
Then write your signature below the closer, and if you have time, print your name below your signature.

(small indent) Yours sincerely,

(small indent) Doctor

N.B it is possible to use Yours faithfully if you start your letter with Dear Sir/Madam
Summary for Important Grammar Rules :
Introductions: 25 words
• Use 2 sentences
• Use Relative Clauses : ……old widower who is due to be discharged today
• Use Appositives: ….. Mr Adrian Lamp to you, an 61-year-old widower.
• Age hyphenated : … , an 61-year-old widower.
Body Paragraphs
• Use of articles
• Transform case notes into complete sentences (compound and complex)
• Use of conjunctions with Contrast , Cause, time and purpose
• Use of verbs (present and past perfect/ active and passive /reported speech)
• Paraphrases adjectives into nouns
• Add cohesion
• Use of adverbial phrases :
 With Sympathy or comment adverbs, such as unfortunately or regrettably
 With Context: On examination,……..
 With Time: On today’s visit, At that time, On review today, On consultation today.
 With Emphasis: Please note, May I remind you, My main concern is....,.
 With Location: During hospitalisation, Initial examination at my clinic revealed...,
 With More information: In addition, Moreover, Also, Apart from this.
 With Subject: In terms of her social history..., With regard to her medication....,Based on …
 With results : Her dental history shows..., The risk factors include....., Treatment includes...
 With Advice: It is important to..., I recommend that you....., Please ensure that....
 With Chronology: Firstly, Secondly, Finally.
Body 1 : Social and medical history, 45 words , Mainly present
 Use compound and complex sentences
 Use Adverbial phrases : Regarding her medical history, Please note, ….
Body 2: Previous visits, 45 words , Mainly past
 Use compound and complex sentences
 Use Adverbial phrases : On 15/01/2018, ……..
 Use Connectors and conjunction …….; thus … and ….therefore,……. , but …..later on, ...
 Use Active and passive sentences
 Use Punctuations marks
 Chronologically arranged : Firstly, Secondly, Finally.
Body 3: Final visit (today), 45 words , Mainly past
 Use compound and complex sentences
 Use Adverbial phrases : Today, Ms.… came reporting that (to) ... Thus, ..
Conclusions: 25 words
Modal Verbs : Could you.. I would be grateful if.. I hope you…..
Conditional Sentences: It would be greatly appreciated if … Please don’t hesitate to call me if…..
OET Writing Template

1. Date : 10/02/2018 Today’s date

2. Address
Dr Lisa Smith Doctor’s name /Admitting officer (if doctor’s name not given)
Endocrinologist specialty
City Hospital address
New town

3. Salutation : Dear Dr. Smith Dear (doctor’s name)

4. Subject + DOB: Re: / RE: Mrs. Priya Sharma Re:(patient’s name)

D.O.B 08/05/1952 (or a/an 54 years of age if no DOB)

5.Body:
Introduction Mainly 2 sentences (25 words)
(small indent) a. Thank you for seeing Mrs. Sharma , (family name)………..
I am writing this letter to refer you Mrs. Sharma , ………..
b. … , a 42-year old accountant…, (job) ….married //(widowed) with two children, ………
c… , whose features are consistent with.. ....
//… , whose features are suggestive of …....
// … , who has recently developed ….....
// … , who is presenting with symptoms and signs are suggestive of....
// … , who is presented at my clinic today with a main concern....
// … , who is complaining of ……....
// … , who is due to be discharged today.
// … , who is suffering from ………….
// … , who has been a patient of mine for a long time. Currently, he is suffering from........………….
// … , who was diagnosed with ……….. on 22 May 2009.....
// … , who was admitted to hospital on the 18th of July, diagnosed with.………...... .
d. Your further management is highly appreciated .
// I would be grateful if you could manage her condition as you think appropriate .
Body 1 : Social and medical history (45-50 words) (mainly present tense)
a. Mrs Sharma is married //(widowed) with two children, ………
b. …..Regarding her medical history she suffers from………. / has been suffering from…
….// she has medical history of ……
,,,,// whose medical records shows that she has long history of…
…// her past medical history reveals that ……
…// her past medical is unremarkable apart from …….

c. for which she has been taking……. . If need long sentence (present perfect/active)
.
…// Which have been managed accordingly If need short sentence
Please note, ….// It is worth mentioning that … the patient has an allergy to...

Body 2 In between visits (45-50 words) (mainly past tense)

a. On 15/01/2018, ……..
b. ……the patient attended my surgery with a two days history of….
……// presented with a two days history of….
…..// came reporting that ..//a two days history of….
c. …….; thus …//therefore,……. ……. one month later, he developed…. later on, ...

Body 3 Final visit (today) (45-50 words) (mainly past tense)

Today, Mrs.… came reporting that (to) ... Thus,...
…..// complaining of ….. Her examination revealed ….. Thus,...

6. Conclusion
a. In view of the above,….. // My provisional diagnosis is……. ; therefore, ….
b. I am referring this patient for further management of her condition.
c. For any queries, please contact me.
….// please do not hesitate to contact me for any assistance you require regarding this patient.

7.Closer:
(small indent) Yours sincerely,

(small indent) Doctor

Typical origination of a referral letter format

1. Name and address of recipient:

2. Date: (The date in the case notes, which will be the date of your OET test)

3. Salutation: (Dear Dr Smith….)

4. Name and age of person referred (e.g. Re: John Watson, aged 71 years)

5. (small indent) Introduction . must be short summarizing

1. The patient’s chief complain.
2. What do you want a recipient to do about it
 It’s often begins with I am writing to refer (name of pt)

6. Body 1 details of the patient’s chief /recent medical history relevant to referral.

7. Body 2: Secondary complaint status /Current medical condition.

8. Body 3: Discharge plan/treatment plan.

9. Conclusion : please do not hesitate to contact me for ……………….

10. (small indent) Sign off (Yours sincerely)

11. (small indent) Your job title (e.g. Doctor)

*NOTE: This is only a suggested typical structure. On test day you must remain flexible and
use whatever structure works best for the case notes in front of you.
Sample referral letter

31 July 2009

The Director
Redeemer Palliative Care Hospital
32 Nelson Drive
St Lucia
Queensland, 4050

Dear Dr. Jones Adam,

Re: Mrs. Carol Brady

DOB 4 February 1968

I am writing to refer this patient, a 42 year old married woman who was diagnosed with stage 4
ovarian cancer on 22 May 2009. I would appreciate it if you could provide respite care for her.

I have been supporting Mrs. Brady and her family for the past 2 months, and she is on palliative
care and now only expected to live for four months. Her husband Mr. Mike Brady is her primary
carer, and he has reduced his work hours to look after her and their children aged 10 and 12. He
usually feels that he is exhausted, emotionally stressed and isolated because he finds it difficult
to cope with all the work at home.

Mrs. Brady is depressed and withdrawn and she does want any visitors. In addition, she has not
been eating much recently. Regarding medication, she takes oxycontin and stemitel twice daily
and is on a regular Panadol. However, her pain is still increasing.

Could you please do a reassessment of Mrs. Brady’s pain medication as it may need to be
increased. Thank you for looking after this patient and please do not hesitate to contact me if
you have any further questions.

Yours sincerely,

Doctor
Sample referral letter for urgent assessment and management

Admitting officer
Emergency Department
Newtown Hospital

13/09/2014

Dear Sir/ Madam

Re: Ms Sally McConville, age 38 year old.

I am writing to refer Ms McConville, a 38- year – old administrator, who presented with symptoms
and signs suggestive of infective exacerbation of asthma. Your urgent assessment and management
would be highly appreciated.

Ms McConville is single and does not smoke. Regarding her medical history, she is asthmatic and
takes fluticasone 250- 2 puffs daily in addition to salbutamol -2 puffs as needed. Please note that she
has no allergies.

Ms McConville presented on 10/09/2014 with a2 day history of symptoms of upper respiratory tract
infection . Her physical examination was unremarkable, she was advised to take the salbutamol
inhaler regularly. Two days later, she attended with worsening SOB, productive cough and high
grade fever .Therefore, oral antibiotics and short course of steroids have be prescribed.

Today morning, Ms McConville is lethargic and her condition further deteriorated . On examination,
temperature 37.7, plus 112, BP 100/65 and RR 25. On chest examination; there is widespread
wheeze and bilateral basal crepitations. I commended her on salbutamol nebulous 5mg.

In review of the above, my provisional diagnosis is pneumonia complicated by acute asthma. The
patient requires urgent attention and management in the emergency department. Should be any
queries do not hesitate to contact me.

Yours sincerely,
Doctor
Typical origination of a transfer letter format

1. Name and address of recipient:

2. Date: (The date in the case notes, which will be the date of your OET test)

3. Salutation: (Dear Dr Smith….)

4. Name and age of person referred (e.g. Re: John Watson, aged 71 years)

5. (small indent) Introduction . must be short summarizing

3. When patient will be transferred
4. Where the patient will be transferred to.
5. The patient’s chief complain and recovery situation.
 It’s often begins with Mr. Watson is being transferred today to intensive care
because his pneumonia has worsened in recent days.

6. Body 1 details of the patient’s chief complain and situation.

7. Body 2: Secondary complaint status /Current medical condition.

8. Body 3: Transfer plan/treatment plan/medication.

9. Conclusion : please do not hesitate to contact me for ……………….

10. (small indent) Sign off (Yours sincerely)

11. (small indent) Your job title (e.g. Doctor)

*NOTE: This is only a suggested typical structure. On test day you must remain flexible and
use whatever structure works best for the case notes in front of you.
Typical origination of discharge letter format

1. Name and address of recipient:

2. Date: (The date in the case notes, which will be the date of your OET test)
3. Salutation: (Dear Dr Smith….)
4. Name and age of person discharged (e.g. Re: John Watson, aged 71 years)
5. (small indent) Introduction . must be short summarizing
6. When patient will be discharged
7. The patient’s chief complain and recovery status. It’s often begins with
 Mr. Watson is being discharged today back into your care after suffering from
pneumonia. He has recovering well.
 I am writing this letter to update you with the status of Ms …
provide details about the condition of Mr ….
to inform you about …..
to discharge Mr … into your care.
6. Body 1 details of the patient’s chief complain and recovery status .
The GP already knows the patient, so no need to mention social and past
medical history, so give less details in this body, or it is better to omit.
7. Body 2: Secondary complaint status /Current medical condition.
8. Body 3: discharge plan/treatment plan/medication.
9. Conclusion : please do not hesitate to contact me for ……………….
10. (small indent) Sign off (Yours sincerely)
11. (small indent) Your job title (e.g. Doctor)

*NOTE: This is only a suggested typical structure. On test day you must remain flexible and
use whatever structure works best for the case notes in front of you.
Sample discharge letter
Example discharge letter: (May 2015)

Dr Lorna Bradbury
Stillwater Medical Clinic
12 Main Street
Stillwater

23/05/2015

Dear Dr Bradbury,
Re: Ms Isabel Garcia D.O.B. 01/01/1995

I am writing this letter to update you with the status of Ms Garcia, a 20-year-old university student,
who is presenting with symptoms and signs suggestive of meningitis. I would be glad if you could
further follow up her close contacts and manage their condition as you think appropriate.

Ms Garcia is a single woman whose medical history is unremarkable except for allergy to certain
washing detergents. Please note, her mother died of breast cancer. We can omit this paragraph

Today, the patient presented complaining of neck stiffness, photophobia and rash. Consequently,
blood tests and lumbar puncture were done which unfortunately revealed that the patient had
bacterial meningitis. Thus, she initially commenced ceftriaxone and dexamethasone; in addition,
she was prescribed benzylpenicilline after the blood culture appeared.

The patient′s close contacts as family members and friends should seek medical attention for the
possibility of having any sign of meningitis as well as giving the recent close contacts
chemoprophylaxis. It is worth mentioning that the Department of Human Services was also notified.

In view of the above, I am referring this patient who has just been treated for further follow up of
her and her close contacts. For further queries, please do not hesitate to contact me.

Yours sincerely,

Doctor
Dr. Mario
City Hospital
15 River Street
Herberton City

27 September 2018

Dear Dr ….
Re: Mrs. Amal Hussin, aged 60 years

Mrs. Hussin, a 60- year old woman who being discharged from our hospital into your care today. she
was admitted into our hospital on the 25 September, with a complaint of chest pain. She has
recovering well.

The patient was suffering from an intense pain at the left chest. There was an increase in this pain
during the day time.
Regarding her medical history, she had a background of ischaemic heart disease with previous
myocardial infarction and CVA. Furthermore, she has been suffering from hypertension, type II
diabetes mellitus and obesity for a long time for which she has been taking aspirin, ACEI and twice
daily Insulin. However, she still complaining of obesity.
Her cardiac examination was unremarkable apart from a local left chest wall tenderness. Moreover,
her 12 lead ECG showed sinus rhythm with old myocardial infarction. There were no sequential
changes and troponin was not raised.

The patient was well at the time of discharge from our hospital, apart from the problem related
to muscle pain.

In view of the above, I felt that her symptoms were consistent with musculoskeletal origin. Therefore,
I would be grateful if you could follow up her condition as you think appropriate .

Please do not hesitate to contact me for any assistance you require regarding this patient. .

Yours sincerely,

Doctor Samed Alsalemi

Letter Punctuation.
Capitalization
When to use Capital Letters & Lower Case :

Rule 1: Medications and diseases

 Capitals are required for the brand name of a drug or registered trademark = Ritalin, Voltaren
 The chemical constituent should be written in lower case. penicillin and aspirin
 Names of diseases should always be lower case = cancer and diabetes
 Eponyms: Some medical conditions are named after the person who discovered it. In this case
the first word should be capitalized = Parkinson’s disease and Bell’s palsy
 Names of medical equipment do not require capitals = orthopantomogram , x-ray
 Body parts should always be lower case = The heart , The adrenal gland

Rule 2: Proper nouns need to be capitalized. includes names of people ,addresses and institution
 Job titles = The Lactation Consultant , Mater Hospital , University of Queensland
 Institutions = Mary was admitted to Spirit Hospital ,Dr. field works at Weller Point Medical Centre.
 Places including addresses = 168 Wickham Terrace, Spring Hill , 12 Logan Road, Mt Gravatt
 Titles when they precede the name of a person = The patient was seen by Doctor Smith.

Rule3 : Common nouns, place, person or profession. These words do not need to be capitalised.
 The patient was admitted to hospital.
 The patient does not have a family doctor.
 Steve is a teacher.
 Yoshiro is a doctor
Rule 4: Holidays, months, days of the week. Exception: do not capitalize seasons.
 The baby was born on Christmas Day.
 The patient was admitted to hospital on January 12.
 Please come and see me on Wednesday.
 The vaccination will be available in spring.

Rule 5: The pronoun “I” must always be capitalized.

Rule 6: Capitalize the first word of a salutation and the first word of a complimentary close.
Common error
Medications and diseases
Incorrect
 His medical history shows that he is
Epileptic although it is well under control
by Dilantin.
 Also,i have given Dycal base on 1.1 and
dressed it with Glass Ionomer Cement. A
tablet form of Paracetamol has also been
given for pain control and relief.
 The patient was diagnosed with Type 2
Diabetes.
 Mrs. Marsh has a history of
Hyperthyroidism, Hypertension and
Glaucoma.
 The patient is allergic to Penicillin.
 The patient suffered from severe
Abdominal pain
 Mr. duane Eddy presented at my clinic
today with the complaint of a broken
posterior tooth.
 The director of nursing
 emergency department
 Mater hospital
 84 Monash road
 The patient was seen by doctor Jones.
The pronoun “I” must always be capitalized.
 The patient requested that i prescribe
antibiotics for the virus.
Capitalize the first word of a salutation and the first word of a complimentary close.
Incorrect
 dear Dr. Roberts
 yours sincerely,
Correct
 His medical history shows that he is
epileptic although it is well under control
by dilantin.
 Also,I have given dycal base on 1.1 and
dressed it with glass ionomer cement. A
tablet form of paracetamol has also been
given for pain control and relief.
 The patient was diagnosed with type 2
diabetes.
 Mrs. Marsh has a history
 of hyperthyroidism,hypertension and
glaucoma.
 The patient is allergic to penicillin.
 The patient suffered from severe
abdominal pain.
 Mr. Duane Eddy presented at my clinic
today with the complaint of a broken
posterior tooth.
 The Director of Nursing
 Emergency Department
 Mater Hospital
 84 Monash Road
 The patient was seen by Doctor Jones.
 The patient requested that I prescribe
antibiotics for the virus.
Correct
 Dear Dr. Roberts
 Yours sincerely,
 Common Nouns:
 The admission’s doctor
Emergency Department
Mater Hospital
 The patient was seen by doctor Jones.
 As per the General Practitioner’s order
we are doing daily home visits and wound
dressing and also assisting him with his
showers.
 Please see your Pharmacist for advice.
 Ms. Gatsby is a University student.
Holidays, months, days of the week and seasons.
Incorrect
 The patient first visited my surgery in
march, 2008.
 Mrs. Green will be discharged from
hospital on wednesday.
 Symptoms of hay fever are worse in
Spring.
 The Admission’s Doctor
Emergency Department
Mater Hospital
 The patient was seen by Doctor Jones.
 As per the general practitioner’s order
we are doing daily home visits and
wound dressing and also assisting him
with his showers.
 Please see your pharmacist for advice.
 Ms. Gatsby is a university student.
Correct
 The patient first visited my surgery in
March, 2008.
 Mrs. Green will be discharged from
hospital on Wednesday.
 Symptoms of hay fever are worse in
spring.
Comma:
Use a comma or a full colon after the name in salutations.
 Dear Mr. Hinges, common practice // Dear Mr. Hinges : more formal

Use a comma for the closing words of any letter. Yours sincerely,

In addresses if put the suburb & postcode on the same line. should be separated by a comma.

Comma with adverbial phrases

 With Sympathy or comment adverbs, such as unfortunately or regrettably
 With Context: On examination, there was slight tenderness in the right fornix.
 With Date: On today’s visit, the patient was pale and sweaty.
 With Emphasis: Please note, May I remind you, the patient is allergic to penicillin.
 With Contrast: The patient's condition has improved. However, a follow up visit is required

Handy Hint:
Do not put a comma between a subject and a verb or a verb and an object.
Put a comma before a subject = Adverbial Phrases ….. , subject + verb + an object
Unfortunately, I suspect the patient has developed ectopic pregnancy
Regarding her medical history, she has been suffering from asthma for which she uses a Ventolin.
On review today, there was no improvement in her condition.
In terms of his medical history, he is a heavy smoker and a heavy to moderate drinker.
Please note, the patient has an appointment with his physiotherapist. 10 o'clock on Monday.
In addition, there are composite and amalgam restorations on several teeth.

Put a comma before a subject without an object = Adverbial Phrases ….. , subject + verb .
On examination, slight right iliac fossa tenderness was revealed.
On examination, a large mesioincisal hard tissues was revealed.

Do not put a comma without adverbial Phrases = subject + verb + an object.

I suspect the patient has developed ectopic pregnancy.
Abdominal examination revealed slight right iliac fossa tenderness .
Clinical examination of hard tissues revealed a large mesioincisal fracture.
Appositives : put a comma bw a noun phrase that is placed after another noun to explain it.
 Thank you for seeing Jordan, a 10 year old boy who presented at my clinic
today with a main concern of pain in tooth.

Conditional Sentences: These sentences are used in the conclusion of referral letter:
Use a comma if clause is at the beginning of the sentence.
 If you could take over her antenatal care, it would be much appreciated.
 If you have any further questions regarding this patient, please don’t hesitate to call me.
Don’t use a comma if the if clause is at the end of the sentence.
 It would be greatly appreciated if you could take over her antenatal care.
 Please don’t hesitate to call me if you have any further questions regarding this patient.

Complex sentences:
Use a comma if the dependent clause is at the beginning of the sentence.
 In case of irritation, redness or swelling, please consult your doctor.
 When the results become available, I will forward them to you.
 Because of her deteriorating condition, the patient was admitted to hospital.
Don’t use a comma if the dependent clause is at the end of the sentence.
 Please consult your doctor in case of irritation, redness or swelling.
 I will forward the results to you when they become available.
 The patient was admitted to hospital because of her deteriorating condition.

Noun Clauses beginning with that should not be separated by a comma.

 It is also important to know that a re-check is organised for the 31.5.2009 at 10:30 in
order to remove the suture.(correct)
 It is also important to know, that a re-check is organised for the 31.5.2009 at 10:30 in
order to remove the suture. (incorrect)

Use commas to separate three or more words, phrases, or clauses written in a series.
The final word does not require a comma and it should be separated by a conjunction such as and/or
 Mrs. Olsen has a history of hypertension, hypothyroidism and glaucoma which is on regular
medication. (correct)
 Mrs. Olsen has a history of hypertension, hypothyroidism, glaucoma for which she is on
regular medication. (incorrect)
Use commas to adding extra information about the subject

In the opening sentence of the referral letter it is common to add extra information about the
patient which is not part of the main sentence. It is a useful strategy as it can reduce the number
of words in the letter. If we removed it, neither the structure nor the meaning of the sentence
would be changed. Commas & brackets are the most common ways of doing this in a referral
letter. However, it can be overused. In this case a comma can be used, but it is not really
necessary as it breaks the flow of the sentence.

 I am writing to refer Mr. Jones , a 57 year old man who was admitted to hospital on the
18th of July, diagnosed with myasthenia gravis.
Common errors
Incorrect Correct
Dear Dr Jones Dear Dr. Jones,
Dear Dr. Jones:
Explanation: Comma or full colon required
Yours sincerely Yours sincerely,
Yours Sincerely
Explanation: The possessive form is used
before nouns, not adverbs

to Dr. Blair Howell, Dr. Blair Howell

28 George Street, 28 George Street
Spring Hill Spring Hill
Queensland 4000 Queensland, 4000

Explanation:
1. To not required.
2. Commas not required when the address is
written top at the letter because the
information is separated lines.
3. Capitals required for job titles
4. Capitals required for street & suburbs.

On review today Mr Walker has reduced On review today, Mr. Walker has reduced
smoking from 20 to 10 cigarettes per day. smoking from 20 to 10 cigarettes per day. (time)

On examination today there was a soft On examination today, there was a soft fluctuant
fluctuant swelling palpable on the left cheek swelling palpable on left cheek. (time)

Regrettably she has problems with breast Regrettably, she has problems with breast feeding
feeding and caring for the baby. and caring for the baby. (concern)

Please note he has a prosthetic heart valve. Please note, he has a prosthetic heart valve.
(emphasis)
 regarding her medical history, she has been
regarding her medical history she has been suffering from asthma for which she uses a
suffering from asthma for which she uses a Ventolin inhale
Ventolin inhaler
Unfortunately,I suspect the patient has developed
Unfortunately I suspect the patient has ectopic pregnancy.
developed ectopic pregnancy.
In addition,there are composite and amalgam
In addition there are composite and amalgam restorations on several teeth.
restorations on several teeth.
I am writing to refer Mr. Jones, a 57 year old man
I am writing to refer Mr. Jones a 57 year old who was admitted to hospital on the 18th of July,
man who was admitted to hospital on the diagnosed with myasthenia gravis.
18th of July, diagnosed with myasthenia
gravis. Mr. Jones, a 57 year old man, was admitted to
hospital on the 18th of July, diagnosed with
Mr Jones, a 57 year old man was admitted to myasthenia gravis.
hospital on the 18th of July, diagnosed with
myasthenia gravis. Mr. Jones, who is 57 years old, was admitted to
hospital on the 18th of July, diagnosed with
Mr Jones, who is 57 years old was admitted to myasthenia gravis.
hospital on the 18th of July, diagnosed with
myasthenia gravis. I am writing to refer Ms. Greerson, a 58 year- old
widow to you.
I am writing to refer Ms Greerson, a 58 year-
old widow, to you.
Letter Grammar & Cohesion

 Articles usage (definitive/ indefinite) with Countable & Uncountable Nouns

 Noun (singular and plural)
 Connecting words and phrases appropriately - long and short sentences conjunctions
 Compound Sentences : These are sentences which contain 2 or more clauses linked
together using a coordinating conjunction (and, but, so, or, for, nor, yet).
 Complex Sentences: These are sentences which contain 2 or more clauses linked together
using a subordinating conjunction (although, as, because, if, since, when, where, while).
 Clauses of Contrast
 Clauses of Purpose
 Clauses of Reason
 Clauses of Time
 Complex Compound Sentences: These are sentences which contain both coordinating and
subordinating conjunctions. This means they will contain at least 3 clauses
 Make the sentence “parallelism” to maintaining consistent structure when linking to phrases.
 linked sentences together into paragraphs to maintaining consistent structure - Cohesive
 Use furthermore ,in addition , moreover”, consequently , therefore , as a result ,however, but
 Relative clauses and Pronouns
 Adjectives , Adverbs and Adverbial clauses
 Verb usage - Tense verbs
 Passive voice
 Reported speech
 Subject/verb agreement
 Use of Modals
 Use of prepositions/ Phrasal Verbs and Prepositions.
Definite & Indefinite Articles

Indefinite: a/ un = singular countable noun/ single object and measurement unit or time.
 "A" + singular noun beginning with a consonant : a doctor, a check-up, a big apple
 A + singular noun beginning with a consonant sound:( 'yoo-zer,' i.e. with a 'y', so 'a' is used);
• a university , a unicycle , a union
 "An + singular noun beginning with a vowel: a – e – i – o – u : an episode , an abscess .
 An + nouns starting with silent "h": because the "h" hasn't any phonetic "an" is used
• an hour , an honorable peace , an honest error
 " If noun + adjective, the choice between a and an depends on the initial sound of the adjective:
• a broken egg , an unusual problem
We use a/an :
 Before a singular countable noun : a doctor , un ache
 Before a job, a particular group of people or a nationality. Saleh is a doctor ,an engineer ,accountant.
 With numbers that mean every : one capsule two times a day.
We DO NOT use a/an:
 No article is used before plural or uncountable nouns. Advice on diet is requested.
 No article is used with abstract nouns and the names of metals. Love, beauty, wood, silver, gold.

Definitive : the = singular/ plural , countable /uncountable noun /specific person or group.
The is used before:
 A noun that is the only one of its kind. The river Nile ,,,,,,, The Ka’aba
 Names of rivers, seas, oceans, etc…. The Arabian Gulf ,,,,,,,, The Red Sea
 A noun which is the object of a sentence. Umar answered the question.
 The names of musical instruments. Can you play the duff?
 Names of some countries. The United Kingdom The U.S.A.
 With some time expressions. at the weekend , in the evening
 With dates. On the first day of every month.
 With some general expressions. Listen to the radio/news.
 Use article with the name that is repeated. I saw a man. The man was young.
We DO NOT use the :
 with the names of countries, cities, towns, streets , mountains and studies of subjects.
 No article is used before such words as school, home, bed, work, etc.I am going to school.
 No article is used before such words such as day and month names. on Monday, in June .
Medical Definite & Indefinite article Usage

Use article to introducing new information Vs previously mentioned information

When you mention something for the first time the indefinite article a/an is required.
However the second and subsequent times that we mention it definite article the is required
 Initially, she came to me on 03/07/06 for a blood test. The results of the blood test were
negative.

Use article “the” to referring to Something Specific

 She was on Microgynon 30 for the previous 5 years

Use “the” for parts of the body

 Pain in the left groin.

Use an article “the” before the nomilisation.

 The patient is complaining of discomfort during the passing of urine.

Always use the definite article with same word.

 She has a family history of the same disease that had been controlled by Risperidone.

Do not use an article for names of diseases or conditions.

 Recently, the patient has complained of headache.

Usually no article is required with gerunds.

 On review today, Mr Walker has reduced smoking from 20 to 10 per day
Common errors
Use article to introducing new information Vs previously mentioned information

Incorrect Correct
 The patient has the family history of diabetes.  The patient has a family history of diabetes.
Explanation: If it is the first time to give this
information then the indefinite article is required for
countable nouns.(first time to give this information)

 Today, the patient reported back with above  Today, the patient reported back with the above
mentioned pain and symptoms. mentioned pain and symptoms.
(second time to give this information)

 In addition, the pain in the right knee joint has  In addition, pain in the right knee joint has appeared
appeared over the last 2 days. over the last 2 days.

 Thank you for seeing, Mr and Mrs Conway, who have • Thank you for seeing, Mr and Mrs Conway, who
presented to me for the fertility advice. have presented to me for fertility advice.
Explanation: If it is the first time to give this
information and the word is an uncountable noun,
such as pain or advice, then no article is required.
Note, this error has a big effect on meaning:
the in this case implies that this subject has been
mentioned previously, which of course it hasn't

 Thank you for seeing this patient, an eight year old  Thank you for seeing this patient ,an eight year old
girl who presented today with the broken left arm girl who presented today with a broken left arm
following the accident at her school play ground.It following an accident at her school play ground.It
has been forty minutes since a accident. has been forty minutes since the accident.
Use article to referring to Something Specific
Incorrect Correct
 She was on Microgynon 30 for previous 5 years.  She was on Microgynon 30 for the previous 5 years
 He has been a smoker for last 12 years.  He has been a smoker for the last 12 years.
 Mr. Roberts has been a resident at our nursing home  Mr. Roberts has been a resident at our nursing
for past 2 years. home for the past 2 years.
 This medication needs to be taken twice a day for  This medication needs to be taken twice a day for
next 3 days. the next 3 days.
Explanation: All the expressions above are referring to a
specific period of time so a definite article is required.
 MrsSangean is currently on following medication:  MrsSangean is currently on the following
karvea 150mg daily, oroxinen 0.1 daily medication: karvea 150mg daily, oroxinen 0.1 daily
Explanation:In this case, the writer is referring to
specific medication. i.e that which follows.
 The patient reported pain in left ankle.  The patient reported pain in the left ankle.
Explanation: Here the writer is referring to a specific
side, i.e not the right side but the left side.
 Patient complained of chest pain. • The patient complained of chest pain.
Explanation: Patient requires an article to indicate
which patient the writer is referring to.
 Examination revealed a slightly swollen joint and a • Examination revealed a slightly swollen joint and a
tender spot on medial aspect of it. tender spot on the medial aspect of it.
Explanation: Here the writer is referring to a specific
region, i.e not the anterior aspect but the medial
aspect.
 Based on above information, I believe the patient  Based on the above information, I believe the
needs urgent admission to hospital. patient needs urgent admission to hospital.
Explanation: Here the writer is referring to a specific
information,i.e not the information on the medical
chart but the information written above.
 Thank you for seeing this patient who presented at  Thank you for seeing this patient who presented at
my surgery regarding tooth 54 which has been my surgery regarding tooth 54 which has been
temporary filled by school dental service. temporary filled by the school dental service.
Explanation: Here the writer is referring to a specific
dental service, i.e not the community dental service
but the school dental service.
Use an article for parts of the body
 Pain in left groin.  Pain in the left groin.
 Pain in right iliac fossa.  Pain in the right iliac fossa.
 I suspect it to be adenoma of parotid gland.  I suspect it to be adenoma of the parotid gland.
 Mr. Smith had an operation on a left knee.  Mr. Smith had an operation on the left knee.
 Use an article before the nomilisation.
Incorrect
 The patient is complaining of discomfort
during passing of urine.
 In addition he had habit of thumb sucking
until age of five.
Use an article with same word.
Incorrect
 She has a family history of same disease that
had been controlled by Risperidone.
 The children were treated by same dentist.
 The medication is same as last time.
Use an article for names of diseases or conditions.
Incorrect
 The patient is suffering from the high blood
pressure.
 Recently, the patient has complained of the
headache.
 The patient was diagnosed with having the
arthritis.
 The patient has had the influenza for three
days.
Exceptions: For some common illnesses the definite article “the” is used.
Incorrect
1. The patient has had flu for three days.
Use an article with gerunds.
Incorrect
 On review today, Mr Walker has reduced the
smoking from 20 to 10 per day
 The patient was advised to stop the drinking.
Correct
 The patient is complaining of
discomfort during the passing of urine.
 In addition he had a habit of thumb
sucking until the age of five.
Correct
 She has a family history of the same
disease that had been controlled by
Risperidone.
 The children were treated by the same
dentist.
 The medication is the same as last time.
Correct
 The patient is suffering from high blood
pressure.
 Recently, the patient has complained of
headache.
 The patient was diagnosed with having
arthritis.
 The patient has had influenza for three
days
Correct
1.The patient has had the flu for three days.
Correct
 On review today, Mr Walker has
reduced smoking from 20 to 10 per day
 The patient was advised to stop drinking.
Nouns (Countable & Uncountable)
Articles Usage with Countable & Uncountable Nouns
Whether an article is required or not depends on the noun that follows. For this purpose nouns
can be classified into two types: countable & uncountable nouns.

A count noun is one that can be expressed in plural form, usually with an "s." For example, "cat—
cats," "season—seasons," "student—students."

A noncount noun is one that usually cannot be expressed in a plural form. For example, "milk,"
"water," "air," "money," "food." Usually, you can't say, "He had many moneys."

Combinations of Nouns and Articles

these,
a, an the this, that no article
those
Count singular XX XX XX

Count plural XX XX XX

No count XX XX XX

For example, complaint is a countable noun as it can be counted. Therefore it is possible to say 1
complaint or 2 complaints .

Advice on the other hand cannot be counted so it is not possible to say 1 advice or 2 advices , The
correct expression is some/any advice or the expression a piece of advice.
Singular

In the singular form an article is usually used before the noun. Example: The doctor received a
complaint from her patient.

NB. Exceptions: The article can be left out if it is replaced with another determiner such as his/her
or this /that or any/each/every. E.g.

 The doctor listened to each complaint.

 Her complaint was recorded.

Plural

In the plural form the article is usually not used before the noun. Example:

 The doctor received complaints from her patients.

try remembering particular patterns with nouns such as:

- Therapy is uncountable (physiotherapy, chemotherapy)
- Tests are countable (a blood test, an x-ray)
- Medication is uncountable (Panadol, beta blockers)
- Body parts are countable (legs, a heart)
 Countable Nouns

Countable Singular form Plural form

nouns Note the use of an article before each noun in Note the absence of the indefinite articles a/an before
singular form, either as a/an/the each noun in singular form, but the definite article
abscess The patient had an abscess on her gum. The patient had 3 abscesses on her gum.
ache The patient reported a dull ache in her The patient suffered from aches and pain.
abdomen.
appointment A follow-up appointment was scheduled. The patient did not attend her follow-up appointments.
cavity The cavity was exposed. The cavities were exposed.
check up The patient attended for a check-up. Regular check-ups will keep you healthy.
complaint If you have a complaint, tell your doctor. If you have any complaints, tell your doctor.
condition You have a condition known as tuberculosis. There are 3 conditions which can indicate the presence
of cancer.
deposit A carious deposit was evident on tooth 32. Carious deposits were evident on teeth 32 & 33.
episode The patient had an episode of heart flutter. The patient reported 3 episodes of heart flutter.
examination An examination is necessary to rule out Blood urine examinations revealed no abnormalities
cancer.
gum The gum surrounding tooth 23 was inflamed. The gums were infected.
swelling There was an increase in the size of the The patient presented with numerous swellings.
swelling.
interpreter An interpreter is required. Interpreters will be required.
investigation An investigation is required to rule out bowel Investigations are required to rule out bowel cancer.
cancer.
limp The patient walked with a limp. All the patients had limps.
parasite The threadworm is a parasite Threadworms are parasites.
lip The patient had a swollen lip. (one lip) The patient had swollen lips. (both lips)
smoker She is a smoker. They are smokers.
operation An operation is necessary. Two operations are necessary.
painkiller The patient requested a painkiller. Painkillers are not necessary with this procedure.
result The patient hoped for a positive result. The results were positive.
review A review was scheduled after 2 weeks. The nurse received positive reviews from her patients.
sensation The patient reported a tingling sensation. The patient experience tingling sensations .
test A blood test was ordered. Blood and urine tests were ordered.
visit Please organise a visit by a social worker. Regular visits by a social worker is required.
Uncountable Nouns
These nouns cannot take a plural form such as: cancer, anaesthesia and information. For these
words no article is required. However, the definite article the as well as quantifiers such as some
and any can be used before the noun.

Uncountable nouns Indefinite articles cannot be used with uncountable nouns.

However definite article “the” as well as quantifiers such as some
and any can be used.
accommodation The patient lives in rental accommodation.
advice Advice on diet is requested.
assistance The patient will require assistance upon discharge.
attention The patient requires urgent attention.
behaviour On examination, the patient's behaviour was abnormal.
cancer The patient has cancer.
concentration The patient has poor concentration.
damage The scan confirmed damage to the medial cartilage.
discomfort If you experience discomfort, please consult your doctor.
information Should you require further information, please do not hesitate to
contact me.
pain The patient experienced pain on palapation.
progress The patient has made good progress.
tissue She has healthy, soft tissue.
treatment The condition did not respond to treatment.
research Further research is required.
surgery The patient chose not to have surgery.
Common mistakes
Incorrect Correct
Wound on her left knee has been stitched. A wound on her left hand has been stitched.

I am writing to refer Marvin, 7 year old boy I am writing to refer Marvin, a 7 year old boy
who was admitted to hospital on 21/11/10. who was admitted to hospital on 21/11/09.

Mr Brown has been patient of mine for 7 years. Mr Brown has been a patient of mine for 7 years.

Please note, the patient has had prosthetic heart Please note, the patient has had a prosthetic heart
valve for year. valve for a year

Examination revealed abscess on her gum. Examination revealed an abscess on her gum.

Apart from bruises to her body, X-rays reveal Apart from bruises to her body, X-rays reveal that
that she has fracture of the right ankle. she has a fracture of the right ankle.

Mr Jones had a heart surgery in 2009. Mr Jones had heart surgery in 2009.

The patient has a cancer. The patient has cancer.

She had a healthy soft tissue. She had healthy soft tissue.

He had lacerated lip and swollen gum. He had a lacerated lip and swollen gums.

The patient has pollen allergy. The patient has a pollen allergy

The patient has tender right elbow joint. The patient has a tender right elbow joint.

The patient presented for regular check-up on The patient presented for a regular check-up on
12/2/10. 12/2/10.
Nouns in the Plural ‫قواعد جمع االسماء‬
...‫( الى نهاية االسم المفرد مثل‬S) ‫ القاعدة األساسية لجمع االسماء هي اضافة‬1-
Book = books , Cat = cats , door= doors 
...‫( الى نهاية االسم المفرد مثل‬es) ‫ ( فعند الجمع يضاف‬z , x , ch , sh , ss , s) ‫اذا كان االسم المفرد منتهيا ﺑ‬2-
abscess = abscesses, bus = buses ,class = classes , brush = brushes 
watch = watches , match = matches 
buzz = buzzes , hex = hexes , box = boxes, quiz = quizzes 
‫( فقط‬S) ‫ (فعند الجمع يضاف‬u , o , i , e , a ) ‫(وكان مسﺑوقا ﺑأحد حروف العله‬Y) ‫ اذا كان االسم المفرد منتهيا‬3-
valley = valleys, way = ways, key = keys, day = days, boy = boys 
(ies)...‫( ويضاف‬Y) ‫( وكان مسﺑوقا ﺑحرف صحيح فعند الجمع يحذف ال‬Y) ‫ اذا كان االسم المفرد منتهيا ﺑحرف‬4-
cavity = cavity , fly = flies 
baby = babies , family = families , lady = ladies 
city = cities , country = countries, factory = factories 
‫ ( الى نهاية االسم مثل‬ves ) ‫( ونضيف‬f , fe) ‫ ( فعند الجمع نحذف‬f , fe) ‫ اذا كان االسم المفرد منتهيا ﺑ‬5 -
wife = wives , wolf = wolves , knife = knives 
leaf = leaves , thief = thieves , half = halves 
life = lives , Calf = calves , Elf = elves 
‫توجد استثناءات لهذه القاعدة وكما يلي‬
roof = roofs , chief = chiefs , belief = beliefs 
dwarf = dwarfs , safe = safes , Gulf = gulfs 
‫( فقط الى‬S) ‫( فعند الجمع نضيف‬u , o ,i , e , a) ‫( مسﺑوقا ﺑأحد حروف العله‬O) ‫( وكان ال‬O) ‫اذا كان االسم المفرد منتهيا ﺑ‬6 -
... ‫نهاية االسم مثل‬
Radio = radios , studio = studios , video = videos 
, ‫( الى نهاية االسم‬es) ‫( مسﺑوقا ﺑحرف صحيح فعند الجمع يضاف‬O) ‫( وكان ال‬O) ‫اذا كان االسم المفرد منتهيا ﺑ‬7 -
...‫ولكن هذا ال ينطﺑق دائما على جميع االسماء مثل‬
echo = echoes, hero = heroes, veto = vetoes, volcano = volcanoes 
potato potatoes tomato tomatoes Domino dominoes 
...7 ‫توجد استثناءات للقاعدة رقم‬-
Casino = casinos , photo = photos , piano = pianos, Kilo = kilos 
: ‫األسماء المركﺑة تجمع حسب االسم األخير‬
policeman = policemen Classroom = classrooms 
:‫هناك ﺑعض األسماء الشاذة‬
people = person , child = children , Man= men 
tooth= teeth Foot = feet 
Goose = geese , Mouse = mice 
‫( اليها‬s) ‫*تجمع المختصرات ﺑأضافة‬
Adjectives with Countable and Uncountable Nouns
Most of the time, this doesn't matter with adjectives. For example, you can say, "The cat was gray"
or "The air was gray." However, the difference between a countable and uncountable noun does
matter with certain adjectives, such as the following:

Some/Any: = ‫ ﺑعض‬Both "some" and "any" can modify countable and uncountable nouns.
• "There is some water on the floor." / "There are some Mexicans here."
Much/Many: = ‫كثير‬
Much" modifies only uncountable nouns. "The horse drinks so much water."
"Many" modifies only countable nouns. "I collected many sources for my paper."
Little/Few: = ‫قليل‬
"Little" modifies only uncountable nouns. "He had little food in the house."
"Few" modifies only countable nouns. "There are a few doctors in town."
A lot of/lots of: ‫وافر = كثير‬
"A lot of" and "lots of" are informal substitutes for much and many. uncountable "" and countable
• "They have lots of (much) money in the bank." / "A lot of (many) Americans travel to Europe."
A little bit of: = ‫قليل‬
"A little bit of" is informal and always precedes an uncountable noun.
• "There is a little bit of snow on the ground."
Plenty of: = ‫وافر‬
"Plenty of" modifies both countable and uncountable nouns.
• "They have plenty of money in the bank." / "There are plenty of millionaires in Switzerland."
Enough = ‫كافي‬
Enough modifies both countable and uncountable nouns.
• "There is enough money to buy a car." / "I have enough books to read."
No = ‫الشي‬
No modifies both countable and uncountable nouns. "There is no time to finish now."

much, less, little, some, any, most, many, both, several, each, every,
a little, very little more, all, a lot of, few/fewer/fewest, a few, any, one
no, none of the one of the, a couple of

XX
Count singular

Count plural XX XX

Non count XX XX
Sentence Structure

 Study language at a clause or phrase level while paying attention to word types.
 Review particular types of clauses and phrase.
 Take steps to master using a variety of different sentence types
 Maintaining consistent structure of words when linking different phrases .“parallelism”,

Take care to use correct phrases and more complex sentences .

 Avoid simple sentence
 Use compound and complex sentences
 Use conjunction …….; thus …// therefore,……. later on, ...
 Use Adverbial phrases :
 Please note, ….
 On 15/01/2018,
 Today, Ms.… came reporting that (to) ... Thus, ...

Paragraph must contain:

Introduction : 25 words
 Use 2 sentences
 Use relative clause
Body 1 : Social and medical history , 45 words
 Use compound and complex sentences
 Use Adverbial phrases : Please note, ….
Body 2: In between visits , 45words
 Use compound and complex sentences
 Use conjunction …….; thus …//therefore,……. later on, ...
 Use Adverbial phrases : On 15/01/2018, ……..
Body 3: Final visit (today) , 45 words
 Use compound and complex sentences
 Use Adverbial phrases : Today, Ms.… came reporting that (to) ... Thus, ...
Phrases ,Clause and Sentences
Phrase is a combination of words forming part of the sentence but without a verb.
 Phrases may be Noun Phrases ‫ أسمية‬,Adjectival Phrases ‫ وصفية‬,Adverbial Phrases ‫ظرفية‬
Clause is a combination of words containing a verb and has a complete meaning.
 Clause may be Noun Clause ‫ أسمية‬,Adjectival Clause ‫ وصفية‬,Adverbial Clause ‫ظرفية‬
Sentences is a combination of subject + verb + object and has a complete meaning.
 Sentences : may be Simple ‫ بسيطة‬, Compound ‫مركبة‬, Complex ‫معقدة‬

Adverbial Phrases
 with Sympathy : unfortunately, regrettably,
 with Context : On examination,
 with Date: On today’s visit,
 with Emphasis: Please note,
 with Contrast: However,

Adverbial Phrases + subject + verb + an object/ Put a comma before a subject

Unfortunately, I suspect the patient has developed ectopic pregnancy
Regarding her medical history, she has been suffering from asthma for which she uses a Ventolin.
On review today, there was no improvement in her condition.
In terms of his medical history, he is a heavy smoker and a heavy to moderate drinker.
Please note, the patient has an appointment with his physiotherapist. 10 o'clock on Monday.
In addition, there are composite and amalgam restorations on several teeth.
Do not put a comma between a subject and a verb or a verb and an object.

Adverbial Phrases + subject + verb no an object./ Put a comma before a subject

On examination, slight right iliac fossa tenderness was revealed.
On examination, a large mesioincisal hard tissues was revealed.

Noun Clauses beginning with that should not be separated by a comma.

 It is also important to know that a re-check is organised for the 31.5.2018 at 10:30 in order to
 remove the suture.(correct)
 It is also important to know, that a re-check is organised for the 31.5. 2018 at 10:30 in order to
 remove the suture. (incorrect)
Conditional Sentences: These sentences are used in the conclusion of referral letter:
Use a comma if clause is at the beginning of the sentence.
 If you could take over her antenatal care, it would be much appreciated.
 If you have any further questions regarding this patient, please don’t hesitate to call me.
Don’t use a comma if the if clause is at the end of the sentence.
 It would be greatly appreciated if you could take over her antenatal care.
 Please don’t hesitate to call me if you have any further questions regarding this patient.

Relative Clauses ( who, whom, Whose ,which , that)

 Defining clauses provide details about the noun. Commas are not required.
 Non-defining clauses provide extra information but do not define it. Commas are required.

Simple sentences = subject + verb , Example:

Do not put a comma without adverbial Phrases = subject + verb + an object.
 I suspect the patient has developed ectopic pregnancy.
 Abdominal examination revealed slight right iliac fossa tenderness .
 Clinical examination of hard tissues revealed a large mesioincisal fracture.
 The patient is allergic to penicillin.
 The patient was tired.
 Mr Smith had not been sleeping well.
 He had been prescribed sleeping tablets.

Compound Sentences: 2 Simple Sentences joined by conjunctions with (and ,but ,so, or ,nor, yet)
 And = the 2nd clause contains a similar idea as the first
 But = the 2nd clause contains an contrasting idea
 So = the 2nd clause expresses a result or outcome of first.
 Or = the 2nd clause contains an alternative idea
Complex Sentences : 2 Sentences = Main Clause + Subordinate Clause
Subordinate Clause may be Noun Clause ‫ أسمية‬,Adjectival Clause ‫ وصفية‬,Adverbial Clause ‫ظرفية‬
A comma is required when the subordinate clause comes before the independent clause.
A comma not required when the subordinate clause comes before the independent clause.
Complex Sentences - Clauses of Contrast . (A comma is used to separate the two clauses)
 However: A comma , is required after however
 Although/Even Though + clause
 Despite/ Inspite of + noun or gerund
 Despite the fact that/ Inspite of the fact that + clause

Complex Sentences - Clauses of Purpose.

 in order to + infinitive
 So that + past reference
 So that + future reference
Complex Sentences - Clauses of Reason. (cause and effect )
 due to/ because of + noun
 for this reason + clause
 because + clause
 due to the fact that + clause
Complex Sentences - Clauses of Time.
 During + noun
 When + time clause
 While + clause
 Ago + past tense

Complex Compound Sentences:

These are sentences which contain both coordinating and subordinating conjunctions.
This means they will contain at least 3 clauses.
We can try linking all three of the simple sentences to make a compound-complex sentence:
 Although Mr Smith had been prescribed sleeping tablets, he had not been sleeping well so was tired.
Relative Clauses ( who, whom, Whose ,which , that, what )
Relative pronouns (who, whom, whose, which, that, what) can be used to combine two short
sentences like conjunctions.
Relative pronouns introduce relative clauses, which are a type of dependent clause.

In the introduction of a referral letter it is common practice to introduce the patient and provide
some relevant details relating to their situation or condition.
The relative clause allows writers to do this in a clear and concise manner.

Definition: A relative clause is the part of the sentence which provides information about the patient.
They can be divided into two types, defining and non-defining.
Defining clauses provide details about the noun being referred to and essential information about the
antecedent in the main clause. Commas are not required.
Non-defining clauses provide extra information about the noun being referred to but do not define it.
It provide non-essential information about the antecedent in the main clause. Commas are required.
In both types , the relative pronoun can function as a subject, an object, or a possessive pronoun

The table of sums up the use of relative pronouns in relative defining clauses:

Function in Reference to
the sentence People Things / concepts Place Time Explanation
Subject who, that which, that
Object that, who, whom which, that where when what/why
Possessive whose whose, of which

The table of sums up the use of relative pronouns in relative in-defining clauses:

Function in Reference to
the sentence People Things / concepts Place Time Explanation
Subject who which
Object who, whom which where when why
Possessive whose whose, of which
 Defining Non-defining
 I am writing to refer this patient who is due to  I am writing to refer this patient, who is due to be discharged
be discharged today. today, for ongoing physiotherapy treatment.

Explanation: The relative clause defines the
object of the main clause i.e Which patient? The
patient who is being discharged.
 I am writing to refer Mrs. Patterson, a 36-year-
old married woman who is suffering from mild
depression.
Explanation: The relative clause defines the
object of the main clause i.e Who? Mrs.
Patterson, a 36-year-old woman.
n.b. In this sentence, the first comma allows
extra information to be added about Mrs.
Patterson.
Explanation: The relative clause provides extra information
(patient is due to be discharged) about the object of the main
clause but does not define it. It could be removed from the
sentence and the meaning would still be clear: I am writing to
refer this patient for ongoing physiotherapy treatment.
 I am writing to refer Mrs. Patterson, who is a 36-year-old
married woman, is suffering from mild depression.
Explanation: The relative clause provides extra information
(Mrs. Patterson is a 36 year old woman) about the subject of
the main clause but does not define it. It could be removed
from the sentence and the meaning would still be clear: I am
writing to refer Mrs Patterson is suffering from mild depression.

Handy Tip

1. Use that if the main clause poses the question WHAT? answered by the relative clause;
2. Do not use that presenting non-essential, additional information (that is, in non-defining
relative clauses); use who or which instead;
3. Use who to refer to people;
4. Use which to refer to things or to refer to the previous clause as a whole;
5. If you choose between who or that, use who in writing;
6. If you choose between which and that, use which in writing;
7. Do not put a comma before that.
8. No name=no comma
In example 1 below, no comma is required as the relative clause is defining the person being
referred to. In example 2, the relative clause does not define the person being referred to
because it is already known. Therefore, If you include the patient's name, commas are required.
1. The doctor who performed the operation is from Iraq.
2. Doctor Yousef, who is from Iraq, performed the operation.
 Incorrect
 Mr. Holmes who lives with his wife in a
government flat, is an aged care pensioner.
Explanation: Commas required as it is a non-defining
relative clause. You can also express this information in a
compound sentence.
 Mr. O'Riley, who lives alone in his own home, and
works as a fencing contractor and has only one
brother.
Explanation: After the second comma a verb is required.
i.e Mr O'Riley works..
 Mrs. Peterson who recently moved to our
retirement village following her husband's death.
Explanation: No relative pronoun needed here as it is a
simple sentence.
 Mr. Brown presented at my clinic today with a
complaint of fractured front teeth in a traumatic
car accident.
Explanation: A relative clause is required to define how
the teeth were fractured. Alternatively it can be written
as two separate sentences.
 I am writing regarding Mr. Jones, a 35 year-old-
male, who was recently diagnosed with with
tuberculosis.
Explanation: Second comma not required as it is a
defining relative clause, i.e it defines Mr. Jones
 I am writing to refer Mrs. Margaret Green, a 66
year old widow with three children, with
complaints of chest pain.
Explanation: Relative clause required here as two
prepositional phrases is confusing.
Correct
 Mr. Holmes, who lives with his wife in a
government flat, is an aged care pensioner.
 Mr. Holmes lives with his wife in a government
flat and is an aged care pensioner.
 Mr. O'Riley, who lives alone in his own home,
works as a fencing contractor and has only one
brother.
 Mrs. Peterson recently moved to our retirement
village following her husband's death.
 Mrs. Peterson, who recently moved to our
retirement village following her husband's
death, has a history of hypertension.
 Mr. Brown presented at my clinic today with a
complaint of fractured front teeth which
occurred in a traumatic car accident.
 Mr. Brown presented at my clinic today with a
complaint of fractured front teeth. This occurred
in a traumatic car accident.
 I am writing regarding Mr. Jones, a 35 year-old-
male who was recently diagnosed with
tuberculosis.
 I am writing to refer Mrs. Margaret Green, a 66
year old widow with three children who is
complaining of chest pain.
  I am writing to refer, Ms. Abbot, a 58 year old  I am writing to refer Ms. Abbot, a 58 year old
widow admitted with pain, dehydration and widow who was admitted with pain,
nausea. dehydration and nausea.

Explanation: Incorrect comma placement and relative

clause required.
 Mr. Fisher was admitted to hospital with the  Mr. Fisher was admitted to hospital with the
diagnosis of obstructive artery disease and end diagnosis of obstructive artery disease which
with quadruple artery bi-pass grafts. required quadruple artery bi-pass grafts.

Explanation: A relative clause is required to define the

treatment.
 I am writing to refer this 14-year-old boy to you  I am writing to refer this 14-year-old boy who
who came to me complaining of a sprained ankle. came to me complaining of a sprained ankle.

Explanation: The relative pronoun must follow the noun

it is referring to.
 I am writing to refer this patient, a 39 year old  I am writing to refer this patient, a 39 year old
widowed woman, who is under our care after widowed woman who is under our care after
being injured in a car accident. being injured in a car accident.

Explanation: No comma required as it is a defining

relative clause.
 Mr. Roberts who is a 72-year-old retired  Mr. Roberts, who is a 72-year-old retired
gentleman was admitted to hospital for acute gentleman, was admitted to hospital for acute
cerebral infarction on 08/03/10. cerebral infarction on 08/03/10.

Explanation: Commas required as it is a non-defining

relative clause and provides extra information about Mr.
Roberts.
Compound Sentences and Coordinating Conjunctions
These are sentences which contain 2 or more independent clauses linked together in middle using a
coordinating conjunction (for , and, nor, but, or, yet ,so)- FANBOYS.
Must be grammatically equal (noun with noun ,present with present and past with past)
And = the 2nd clause contains a similar idea as the first
 = subject + verb + and + verb + object (No subject, (no need write (,) before)
 Example: She does not smoke and drinks alcohol rarely.
But = the second clause contains an contrasting idea
 = subject + verb + (,)+ but + perfect sentence after (No subject, No verb (need write (,) before)
 Example: She does not smoke, but is a heavy alcohol drinker.
Or = the second clause contains an alternative idea
 = subject + verb + Or + verb + object (No subject, (No need write (,) before)
 Example: She does not smoke or drinks alcohol
So = the second clause expresses a result or outcome of first.
 = subject + verb + so + verb + object
 Example: She does not smoke or drink alcohol so her health is good.

Note
• No subject after the conjunction and (no need write (,) before)
• No subject or verb after the conjunction but (must write (,) before and perfect sentence after)
• No conjunction between noun and adjective
One important decision for the writer to make is whether to include a subject in the second clause.
Basically, the rule is you need to add a subject after a conjunction
 if the subject of the second clause is different to that of the first clause.
 Or if the sentence is very long.
= subject + verb + and + different subject + verb + object (no need write (,) before)
In this sentence, there are two ideas are joined by the conjunction and. Note that the subject for
each clause is different and each clause can function as a complete sentence

 I prescribed Panadol for his hand pain and he was advised to reduce weight and do exercise.
(In this case you must add a subject after and as the subject is different in the second clause)
 I prescribed Panadol for his hand pain and advised for weight reduction and exercise. (in this
case you can omit the subject I as it is the same as the subject for the first part of the sentence)
 I prescribed Panadol for his hand pain and I advised for weight reduction and exercise. (this is
grammatically correct, but in terms of style not very good as it is clear the subject remains the
same, so no need to repeat it)
Common Mistakes

Incorrect Correct
 Nicole is a non-smoker and no drink alcohol or other  Nicole is a non-smoker and (she) doesn’t drink alcohol
drugs. or take drugs.
Explanation: The sentence is not balanced and there is
no verb after the conjunction and

 The wound has healed and free of infection  The wound has healed and (it) is free of infection
Explanation: Omission of subject and verb

 The parents say that immunizations were given at
birth to both their children, but no record to prove
that.
Explanation:No subject or verb after the conjunction but
 Mr. Smith’s activities were restricted since last year
by grinding pain in the left hip and had difficulty in
climbing and descending stairs.
Explanation: No subject after the conjunction and, and
note the subject for each clause is different. In the first
clause the subject is Mr Smith’s activities and in the
second clause the subject is Mr Smith (not his activities)
 The parents say that immunizations were given at
birth to both their children, but they have no records
to prove that.
 The parents say that immunizations were given at
birth to both their children, but there are no records
to prove that.
 Mr. Smith’s activities were restricted since last year by
grinding pain in the left hip and he had difficulty in
climbing and descending stairs.

 Her blood pressure was 175/95 and took normison 1  Her blood pressure was 175/95 and she took
tablet and 2 panadol at 10 pm. normison 1 tablet and 2 panadol at 10 pm

Explanation: You must add a new subject here as it is

different to the subject of the first clause Her BP Vs She
 She is a widow and a resident at Golden Pond  She is a widow and a resident at Golden Pond
Retirement Village, has a son in Warwick. Retirement Village and (she) has a son in Warwick.
Explanation: This error is called a comma splice. A
comma splice is incorrect because two sentences cannot
be joined with a comma alone. In this case you can join
the sentences with and.
 Mr. Jones has been a patient of mine since 1999 and  Mr. Jones has been a patient of mine since 1999 and
attending my clinic on a regular basis for scaling and (he) has been attending my clinic on a regular basis for
cleaning. scaling and cleaning.
Explanation: incomplete verb formation after and
Parallel Structures & Balanced Sentences in Compound Sentences Conjunctions
The information in the case notes is usually written in note form, and therefore does not follow
conventional grammatical rules. However, when this information is organised into complete
sentences in the referral letter it is necessary to follow standard conventions of grammar and
sentence structure. This worksheet explains how to group information using parallel structures to
ensure that the sentences you write are grammatically balanced. This can be achieved by making
sure that verbs, adjectives, nouns, prepositions, phrases and clauses are parallel.

Parallel structures within a sentence are joined with coordinating conjunctions such as and/or as
well as with commas. Here are some examples:

With active verbs

 He is now worried about his condition because he is overweight, lacks exercise and smokes
regularly

With passive verbs

 During hospitalization, IV fluids were commenced and a transdermal patch was used for her pain.

With nouns & noun phrases

 He is now worried about his condition because of his increased weight, lack of exercise and his
habit of smoking.
 He will require information about how and when to take his medication, how to stop smoking and
the necessity of doing regular exercise.

With gerunds
 In order to handle the above mentioned effects be cautious when driving a car, operating
machinery or performing any hazardous activities especially after taking your regular dose.

With prepositions
 Threadworms resemble pieces of 1.5 cm cotton thread which is normally detectable at the surface
of the feces or around the anus at night.

With verbs in the conclusion

 I am worried about Miss Jones and would appreciate your urgent assessment and treatment as you
think appropriate.
The important point to remember is that the structures must be balanced.
 Common Mistakes
Incorrect
 Sally initially presented alone to my clinic on
27/12/07 with a 3-month-history of constipation and
associated using laxatives
Explanation: sentence is not balanced as noun phrases
 He has a family history of stroke and diabetic.
 Explanation: This sentence is not balanced as stroke is
a noun and diabetic is a adjective
 Good hygiene should be maintained by taking a
morning shower, using individual towels, washing
clothes daily and to vacuum regularly.
Explanation: the final verb is out of balance
 I am writing to refer this patient, a 26 year old
computer programmer, who is displaying sign and
symptoms consistent with subdural haematoma.
Explanation: Both nouns should be in plural form
 His height is 170cm and weighing 99kg.
Explanation: unbalanced word form, height is a noun,
weight is a gerund
 On subsequent visits, impressions for full upper and
lower dentures were made, bite registered and
complete upper and lower dentures were delivered .
Explanation: Passive form required for all verbs
 She diagnosed with hyperthyroidism in 1997,
hypertension in 2003 and Glaucoma since 2004.
Explanation: Time markers need to be balanced.
 During hospitalization, IV fluids were commenced and
used a transdermal patch for her pain.
Explanation: Passive form required for all verbs
 Further examination revealed dry mouth, dentures
were worn out on occlusal surfaces and a heavy
calculus deposit was seen on the dentures.
Explanation: In example 1, by adding in addition, you
can change the structure and keep the sentence
balanced. In example 2 the sentence is balanced as
the verbs have been replaced with noun phrases.
 She is feeling loneliness and isolated due to losing her
social contacts
Explanation: Loneliness is a noun whereas isolated in
an adjective so the word forms are not balanced.
Correct
 Sally initially presented alone to my clinic on 27/12/07
with a 3-month-history of constipation and associated
use of laxatives
 He has a family history of stroke and diabetes
 Good hygiene should be maintained by taking a
morning shower, using individual towels, washing
clothes daily and vacuumming regularly.
 I am writing to refer this patient, a 26 year old
computer programmer, who is displaying signs and
symptoms consistent with subdural haematoma.
 His height is 170cm and weight is 99kg.
 On subsequent visits, impressions for full upper and
lower dentures were made, bite registration was taken
and complete upper and lower dentures were
delivered
 She was diagnosed with hyperthyroidism in 1997,
hypertension in 2003 and Glaucoma in 2004.
 She has had hyperthyroidism since 1997, hypertension
since 2003 and Glaucoma since 2004.
 During hospitalization, IV fluids were commenced and
a transdermal patch was used for her pain.
 Further examination revealed dry mouth. In addition,
her dentures were worn out on occlusal surfaces and a
heavy calculus deposit was seen on the dentures.
 Further examination revealed dry mouth, worn out
dentures on occlusal surfaces and heavy calculus
deposits on the dentures.
 She is suffering from loneliness and isolation due to
losing her social contacts. (nouns)
 She is feeling lonely and isolated due to losing her
social contacts. (adjectives)
Complex Sentences
These are sentences which contain 2 or more clauses linked together using a subordinating
conjunction (although, as, because, if, since, when, where, while, and several more…). Unlike
compound sentences, a complex sentence can have the conjunction at the start or middle of a
sentence and will require a comma sometimes. In addition, the two clauses are not seen to be
equally as important as each other. This means that a complex sentence can be very effective when
used well but should only be used in the right situation.

Clauses of Contrast
Contrast can be expressed by joining two clauses with the following linking words: although /
despite/ despite the fact that /even though/ however/in spite of/ on the other hand/ whereas/
while. A comma is used to separate the two clauses as illustrated below.

Although/Even Though + clause

 Although + her condition has improved, she is still very weak.

Despite/ Inspite of + noun or gerund

 Despite an improvement in her condition, she is still very weak.
 Despite overcoming her illness, she is still very weak

Despite the fact that/Inspite of the fact that + clause

 Despite the fact that there has been an improvement in her condition, she is still very weak.
 Despite the fact that her condition has improved, she is still very weak.

However : A comma is required after however

 Her condition has improved. However, she is still very weak

While + clause
 While her condition has improved , she is still very weak
 Common Mistakes

Incorrect Correct
 Inspite of providing with exercises and compensatory  Inspite of our provision of exercises and
techniques she was unable to cope with training due to compensatory techniques, she was unable to cope
an increase in pain. with training due to an increase in pain.

Explanation: providing is incorrect, as it was the patient

who was provided excercise, in such cases you have 2
choices  Inspite of being provided with exercises and
compensatory techniques, she was unable to cope
1. Use a noun phrase In spite of our provision of exercises with training due to an increase in pain.
2. Use passive voice In spite of being provided with
excercise

 Although she has improved, but she is still very weak  Although she has improved, she is still very weak.
 She has improved, but she is still very weak.
Explanation: This sentence has two linking words so one
must be omitted.

 Despite of regular follow up, plaque and tartar were  Despite regular follow up, plaque and tartar were
detected over cervical and bucal surfaces of the denture detected over cervical and bucal surfaces of the
teeth. denture teeth.

Explanation: There is no linking expression “despite of”

 Inspite of regular follow up, plaque and tartar

were detected over cervical and bucal surfaces of
the denture teeth.

 Despite of this advice, he regularly drinks 2~4 glasses of  Despite this advice, he regularly drinks 2~4 glasses
wine every night as well as 1~2 glasses of scotch at of wine every night as well as 1~2 glasses of scotch
weekends. at weekends.

Explanation: As above

 Inspite of this advice, he regularly drinks 2~4

glasses of wine every night as well as 1~2 glasses
of scotch at weekends.
 Clauses of Purpose

Purpose clauses allow the writer to express why a certain action was taken in the past or why a
certain action needs to be taken in the future. It can be expressed by joining two clauses with the
following linking words: in order to; so that. A comma is required when the subordinate clause
comes before the independent clause.

Rules
in order to + infinitive:
Handy Tip: in order to rule out + disease name is a useful phrase for introductions or conclusions.
 Further investigation is required in order to rule out bowel cancer.
 in order to rule out bowel cancer, further investigation is required.
 In order to rule out ectopic pregnancy, I would appreciate your urgent assessment.
 The patient wants to have a scan for nuchal translucency In order to rule out Down's
Syndrome

So that + past reference:

 A general anaesthetic was given so that the patient would not feel pain.

So that+ future reference:

 A general anaesthetic needs to be given so that the patient will not feel any pain.

Incorrect Correct
 In order for alleviation of pain, the patient was  In order to alleviate of pain, the patient was
prescribed paracetamol. prescribed paracetamol.

Explanation: In order must be followed by to + infinitive

verb, not for + noun
Clauses of Reason
In referral letters it is often necessary to state why a certain action was taken and clauses of reason
allow the writer to do this in a clear manner. It can be expressed by joining two clauses with the
following linking words: due to/due to the fact that; for this reason; because/ because of.

Rules
due to/because of + noun (underlined below)
 Due to a low fat diet, the patient's health improved.
 The patient's health improved due to a low fat diet.
 Because of a low fat diet, the patient's health improved.
 The patient's health improved because of a low fat diet.

due to + gerund (-----ing form)

 Due to losing weight, the patient's health improved.

for this reason+ clause (underlined below)

 The patient was placed on a low fat diet. For this reason,her health improved.

because + clause
 Mrs Healy's health improved because she was on a low fat diet.
 Because she was on a low fat diet, Mrs Healy's health improved .
 Because of her deteriorating condition, the patient was admitted to hospital.
 The patient was admitted to hospital because of her deteriorating condition.

due to the fact that + clause

 The patient's health improved due to the fact that she was on a low fat diet.
 Due to the fact that Mrs Healy was on a low fat diet, her health improved.

Handy Tip:
due to + ing form allows the writer to express meaning clearly and concisely so it is useful in
referral letters.
Comma placement
A comma is required when the subordinate clause comes before the independent clause. However,
if the independent clause comes first, no comma is required.
 Incorrect Correct

 The patient is feeling lonely and isolated due to  The patient is feeling lonely and isolated due to
lose her usual social contacts. losing her social contacts. (clear and concise)

Explanation: Incorrect word form and sentence

structure after due to  The patient is feeling lonely and isolated due to
the fact that she lost her social contacts.
(formal and a bit wordy)

 His mother had difficulty in caring for both her  His mother had difficulty in caring for both her
son's illness and looking after two other small son's illness and looking after two other small
children due to sick. children due to her sickness.

Explanation: Incorrect word form and sentence

structure after due to
 His mother had difficulty in caring for both her
son's illness and looking after two other small
children due to being sick.

 Recently, the Mr Hutton stopped playing sport  Recently, the Mr Hutton stopped playing sport
because muscle soreness. because of muscle soreness.

Explanation: Incorrect word form and sentence

structure after because of
 Recently, the Mr Hutton stopped playing sport
because he had muscle soreness.
Clauses of Time

A very important part of referral letters is summarising the patient history and order of events in the
case notes. The use of time conjunctions help the writer express these relationships clearly. Commonly
used conjunctions include: ago, during, when, while, since,first, on the next visit, at that time,after,
later, in .......... time etc. etc.
Example sentences
 The patient first saw me three months ago complaining of painful wisdom teeth.
 During hospitalisation, the patient had surgery to remove a suspicious lesion on his lip.
 When Mr. Matthews is discharged, he will need assistance with showering and general household
chores.
 While you are on this medication, please do not drive or consume alcohol.
 Since being admitted 3 weeks ago, the patient has steadily improved and is due to be discharged.
 The patient first attended me yesterday evening
 On the next visit, Peter's condition had worsened and he was very anxious.
 Mr. Hauritz initially presented at my clinic on 20/11/09.
 At that time, examination revealed carious lesions on several teeth along with poor dental hygiene.
 On review after three months, she had made good progress with her weight reduction.
 The patient was advised to reduce alcohol consumption, avoid heavy lifting and review in three
months time.
 A review consultation was scheduled for one month later.
Example paragraph
Six months ago, Mr. Roberts twisted his right ankle while playing golf. During the following months, the
patient experience intermittent attacks of pain which hindered his ability to work effectively. On
review after three months, the right ankle joint was x-rayed and the result appeared to be satisfactory.
However, when the swelling, pain and impaired improvement persisted, an MRI was ordered which
revealed a detached cartilage.Currently, Mr. Roberts does not have full mobility, and is no longer
capable of full-time employment on which, financially, his family depends.
Rules :
During + noun (underlined below) = During his stay in hospital, Mr Mason's condition has improved.
When + time clause (underlined below)
 When Ms. Song returned today, she was pale and distressed.
 When the results become available, I will forward them to you.
 I will forward the results to you when they become available.
While + clause (underlined below) = While waiting in reception, the patient fainted.
Ago + past tense (underlined below) = The patient had a liver transplant 12 months ago.
Comma Placement

A comma is required when the time clause comes before the independent clause

Handy Tip

Correct verb tense is an important point to consider when writing time clauses.
The important points to remember are as follows:
When the verb of the time clause is in present form, the verb in the main clause must also be present
or future form. Example: While you display symptoms of fever and rash, you are still infectious.

When the verb of the time clause is in past form, the verb in the main clause must also be in past
form. Example: When the patient received his results, he fainted.

When the verb in the main clause is in present perfect form,the verb of the time clause must be in
present perfect form. Example: While the patient has been in hospital, his condition has steadily
improved.

Incorrect Correct

 Today, the couple presented at my clinic. Mrs. Conway  When the couple presented at my clinic today, Mrs.
informed me that her home ovulation prediction test Conway informed me that her home ovulation
showed positive. prediction test showed positive.

Explanation: To demonstrate a higher level of English

proficiency this information should be expressed in a
complex sentence rather than two simple sentences.
 The patient has had placement of a prosthetic heart  The patient had placement of a prosthetic heart valve
valve 12 months ago. 12 months ago.

Explanation: has had is present perfect, but simple past is

required with the time marker ago.
Cohesive Paragraphs

Example Cohesive Paragraphs

Doctors
Initially, I saw Mr. Jones last month when he came for check-up. At this time his blood pressure
showed a mild elevation (165/90).Also his weight was above the normal limit (85 kg while his
height is 173 cm). However, the cardiovascular examination and the urinalysis were normal.
Therefore I advised him to lose weight, to stop smoking cigarettes and to come for a review visit
within one month. A prostate specific antigen test was requested to be done before the next visit.

Dentists
Initial examination on 20/ 02/ 2008 revealed that 54 has a temporary filling with a cavity extending
through the furcation. Based on the bitewing radiological findings, I advised both 54 and 65 be
extracted along with the construction of a space maintainer. Moreover I advised the filling of
carious 55 and fissure sealant for all 6’s. In my view, general anaesthesia is the proper sedation as
the patient is known to be uncooperative in a dentist chair.

Nurses
When admitted to this hospital, Mr. Jagger complained of haemetemesis, anorexia, dizziness
associated with weight loss and anaemia. He also was suffering from severe epigastric pain after
meals. Therefore, his stool was examined and an endoscopy has been performed.
Some useful cohesive devices which can help you present your ideas clearly and logically:

Time: At that time, On review today, On consultation today, Recently, Over the past 3 weeks....,
Two weeks later, On her next visit, During, Since that time, Initial examination..., On 19/08/10...

Location: During hospitalisation, Initial examination at my clinic revealed..., On examination....

More information: In addition, Moreover, Also, Apart from this..

Advice: it is important to….. please ensue that….. I recommend that you

Contrast: However, Despite, In spite of, Although, Though,

Result: Therefore, Consequently, Hence, As a result, For this reason...

Emphasis: Please note, May I remind you, My main concern is...., What concerns me most is.....

Sympathy: Unfortunately, Regrettably, Fortunately,

Subject: In terms of her social history..., With regard to her medication....,Based on the blood test
results....., Regarding
her medical history....., Her dental history shows..., The risk factors include....., Treatment to date
includes...
 Useful signal markers
Letter Signal Marker Example Sentence
a.  ____as well as_  She suffers from oedema as well as bladder incontinence and
only tolerates fluids.

 as a result of  This child was admitted with Acute Meningoencephalitis as a

result of a complication following Mumps.

 as a result  Let me inform you that that the patient has proven to be
uncooperative during his dental treatments. As a result, I
would recommend the treatments be carried out with a
general anaesthetic.

 On vaginal examination cervical excitation was noted along

 along with
with tenderness in the right fornix.
 apart from this
 She looked very anxious and was having trouble sleeping. Apart
from this, no abnormalities were found on rectal,
cardiovascular and respiratory examinations.
 at that time
 Initially, I saw the patient six months ago when she complained
of constipation. At that time, her physical examination was
normal.

b.  besides that  The patient has smoked 40 cigarettes a day for 25-30 years.
Besides that he has type 2 diabetes.
 because of this  He smokes 20 cigarettes and drinks 2 beers every day. Because
of this, he has been told to cease smoking and to reduce
alcohol.
 based on  Furthermore, a fine needle aspiration was taken and was
investigated. Based on that, I suggest the dog has developed
lymphoma.
c.  consequently  The depth of periodontal pocket was 3.4mm.Consequently, he
has undergone extensive treatment for carious lesions and
oral hygiene maintenance.

d.  during_________  During hospitalization, his vital signs have been monitored and
he has been assisted with his showers.
  On 15/2/08, she presented complaining of lower abdominal
 duration pain of 1 day duration.

 despite  Despite various dental treatments and regular dental cleaning,

his general gum condition is only fair.

f.  for this reason  Mr. Fox's blood pressure was elevated and he was overweight.
For this reason the patient was advised to do exercise and
follow a healthy diet.
h.  Hence  The carious lesions on 65 are reasonably deep and hence the
tooth has to be extracted.

 The patient regularly visits the dentist and her oral hygiene
 however status is good. However, her gums are inflamed.

i.  in terms of ___  In terms of her medical history, she has mild hypertension and
a 12 year history of diverticulitis.
 in order to  I have prescribed agleam in order to reduced anxiety.

 Regarding the medical history, Alfie had a history of thumb

 in addition sucking until the age of 5. In addition, he is epileptic and uses
dylantin to control the attacks.
 in the meantime  I have planned to review him in two months to monitor his
blood pressure and smoking reduction. In the meantime, I
believe he needs urological assessment.
 in case of  In case of any irritation, redness or swelling of the skin,
discontinue the treatment and consult your doctor
immediately

m.  may I remind you  May I remind you that both the teeth will require root canal
that… treatment and crown.

 my main concern is  My main concern is that the patient is reluctant to breastfeed

that… and confident in caring for her baby.

n.  It should be noted  It should be noted that they may have a problem with
communicating in English as they understand limited English.
o.  over……  Over the past week, she has remained free from severe pain
and has been tolerating a fluid diet.
 She first presented to me on 3.7.06 with several episodes of
heart flutter over the previous few weeks.

 on review today,  On review today, the patient has reduced smoking to 10

cigarettes a day, attended gym twice a week and lost 7kg so
far.
p.  please note  Please note, he has an allergic reaction to nuts.

r.  regarding  Regarding his medical history, Jordan suffers from eczema and
asthma for which he receives treatment twice a year.

 regrettably  Regrettably, she complains of mild constipation and weakness.

 recently  Recently, she has been prescribed Karvea 150mg and Oroxine
0.1mg per day, Timoptol Eye Drops 0.5% twice a day and
Normison 10mg as required.
s.  since then  His urinalysis and examination were normal except obesity and
borderline hypertension. Since then, he has been doing
regular exercise and has managed to lose 8kg of weight
t.  therefore  Her vital signs were normal, but she was overweight (85 kg).
Therefore she was advised to reduce weight and do exercise.

 the reason for  The reason for the referral is to consider a possible prostate
biopsy regarding the patient’s condition.
u.  up until now,  Up until now, Mr. Hutton has lead a very unhealthy life.

 unfortunately  Unfortunately, she is not expected to survive more than 3

months.
w.  with regard to  I am writing with regard to this patient, a 57 year-old married
man who is under our care with the diagnosis of myasthenia
gravis.
Tense verbs and Tenses & Voice

Take care to use correct verb tenses -this contributes to your scores for Appropriateness of Language
as well as Linguistic Features.

 Review verb form used to indicate a present time, past time or future time
 Present time (what a patient doing now)= added s to verb with he, she and it.
 Past time (what happened to a patient in past)
 future time (what needs to happen to a patient in next days)
 past perfect to refer to describing two events which are both in the past
 Use the passive voice > active voice = blood tests were ordered , she was instructed to commence
 Negative for I have, with simple past = did not have / with past perfect = had not had
 Use the reported speech

Paragraph must be :
Introduction : 25 words
 Use 2 sentences , mainly present tenses

Body 1 : Social and medical history , 45 words

 Use mainly Past + present perfect tenses
 Use Active > Passive form

Body 2: In between visits , 45words

 Use mainly past & past perfect tenses
 Use reported speech

Body 3: Final visit (today) , 45 words

 Use mainly past tenses
 Use Active & Passive form
Sequence of Tenses
Present Tense
 I do \ I walk
Present Continuous Tense
 I am doing \ I am Walking
Present Perfect Tense
 I have done \ I have walked
Present Perfect Continuous Tense
 I have been doing \ I have been walking

Past Tense
 I did \ I walked
Past Continuous Tense
 I was doing \ I was walking
Past Perfect Tense
 I had done\ I had walked
Past Perfect Continuous Tense
 I had been doing \ I had been walking

Future Tense
 I will do \ I will walk
Future Continuous Tense
 I will be doing \ I will be walking
Future Perfect Tense
 I will have done \ I will have walked
Future Perfect Continuous Tense
 I will have been doing \ I will have been walking
 Simple Present Tense :
We use the present simple to talk about actions happens every day and we see as long term or permanent.
We use the simple present tense when:
 the action is general
 the action happens all the time, or habitually, in the past, present and future
 the action is not only happening now
 the statement is always true
 Usually used with always, usually, often, every day/year/ month /Sunday /weekend, hardly ever , on Saturday, at 7:
00, sometimes ,see examples

Present or Action Condition General Truths

 The patient takes aspirin daily  The smoking cause a lung cancer

Non-action; Habitual Action Future Time

 he hates drugs.  The surgery start at 4:00 p.m. tomorrow.

Question : auxiliary verb do / does + Subject + verb Negative: don't/ doesn't + main verb
 Do you like hospital ? // does he like hospital ?  I don’t like hospital // He doesn’t like hospital .

With verb Be : Passive: object + auxiliary verb be + past participle

Subject + verb be + object (no auxiliary verb)  Aspirin is taken daily
 Positive : I am a doctor.
 Negative : I am not a doctor.
 Question : Is he sick? …Yes, he is .. No , he isn't.
We add (s) to the verb , if pronouns ( He , She, it) and verb ends with a consonant letter or ( e).
Positive: He often smokes at a weekend.
Negative: He does not smoke.
Question : does he smoke ? ..Yes , he does / No , he doesn't
We add (es) to the verb , if the pronouns (He , She, it) and verb ends with( o , ss ,es, sh, ch , x , z ).
 go = goes ,.. pass = passes ,..poses = poseses ,..wash = washes ,…Watch = watches ,… fix =fixes ,…Buzz = buzzes

We add (ies) to the verb , if the pronouns are ( He , She , it ) and the verb ends with ( y )and before the (y) is a
consonant letter and we directly omit the (y)and add (ies) .
 Cry = cries ,..Try = tries ,..Dry= dries ,…Study= studies

if before the (y) is a vowel letter we directly add (s).

 Play = plays , … say = says ,.. Pray = prays ,… stay = stays ,…. buy = buys.

)‫في النفي او السؤال الحظ إعادة الفعل إلى أصله (التصريف األول‬
 Present Continuous Tense: be (am, is and are) + verb + ing
An action is in progress during a particular time, is used to talk about present situations which we see as short term
or temporary. Usually used with Now, right now, at the moment, look , listen etc.

The action is taking place at the time of speaking Activity in

TheProgress.
action is true at the present time but we don't think
 she is bleeding / He is feeling sad. it will be true in the long term.
 They are considering making brain scan.

The action is at a definite point in the future and it has already been arranged.
 I'm meeting my patient at 6.30.

Question: Be + Subject + Complement ? Negative: be + not + verb + ing

 are you taking aspirin daily?  The patient is not taking aspirin daily.
Yes, I am, …..No, I am not……

with verb Be : Subject + verb be (no auxiliary verb) Passive:

Positive : I am a doctor. auxiliary verb be + being + past participle
Negative : I am not a doctor.  Aspirin is being taken daily. (passive)
Question : Is he sick? …Yes, he is .. No , he isn't.

Basic rule Just add -ing to the base verb:

There some verbs we can’t add -ing to the base verb
•know-realize-understand-recognize – believe – feel -suppose-think-imagine -doubt-remember-forget-want-need-prefer
•love-like-appreciate-hate-dislike-fear-envy-mind - care
•possess-have-own-belong
•taste-smell-hear-feel-see
•seem-look-appear-cost-owe-weigh-be-exist-consist of- contain-include
How to add : '-ING' to a verb?
1 When the base form ends in the vowel 'E', simply delete e and added ing:
2 dance=> dancing …..smile => smiling …….bake => baking ……….write => writing
3 When the base form ends in '-IE', the two vowels are replaced by 'Y' and added ing :
4 lie => lying ,….die => dying ,…….tie => tying
5 When the base form ends in '-EE, or - O ,directly added ing :
6 see => seeing ,…..go => going
7 Verbs with one syllable and ending with 1vowel + 1 consonant double last and added ing:
 Sit === sitting ,…Get === getting ,…Dig ===digging ,…Swim == swimming ,…shop== shopping
Exceptions: ( ‫ ) استثناءات‬there can't be 'xx' or 'ww' : Fix === fixing ,…..Snow === snowing
Verbs with two syllable ( 1st syllable stressed)and ending with 1vowel + 1 consonant double last consonants and
added ing: visit === visiting ,….happen === happening
Verbs with two syllable ( 2nd syllable stressed)and ending with 1vowel + 1 consonant double last consonants
and added ing: begin === beginning.
Present perfect Tense: has / have + past participle
used to describe an event which starts in the past and continues until the present.
Mastery of this pattern is an essential for writing successful referral letters.
(Please note that British and American English have different rules for the use of this tense.
The explanation and exercises here refer to British English. In American English, it is often acceptable to use the past
simple in some of these examples.)

With state that begin in the past and lead up to and
include the present
 The patient has had hyperthyroidism since 2007
 The patient's condition has deteriorated over the
past 3 months.
To express habitual or continued action
 He has been a smoker for a period of 25 years.
 He has tried to quit smoking several times over
the past 25 years.

To express duration of an action that began in the past, has continued into the present, continue into the future
 treated Mr. Smith at this hospital for 3 years. / I have been treating the patient since 2005.

Question:
Negative:
has / have + Subject + past participle + yet ?
has / have + not + past participle
 has the patient ever taken aspirin?
Subject + has / have + never + past participle
 Has he visited his doctor yet ?
 He has not had bowel motions for 3 days.
 I haven’t seen this patient since December 200
 The patient has not taken aspirin regularly over
the past 25 yrs.
 He Hasn’t visited his doctor yet
 he has never treated him.

Passive:
 Aspirin has been taken daily for a period of one year.
 Aspirin has been taken daily since 2012.
 Aspirin has been taken irregularly over the past 25 yrs.

WARNING:
We do not use the present perfect with an adverbial which refers to past time which is finished:
 I have seen that film yesterday. X / we have just bought a new car last week. X
But we can use it to refer to a time which is not yet finished:
 Have you seen Helen today? ✔ / We have bought a new car this week.
 Present Perfect Continuous Tense : has / have + been + verb + ing .
This tense is used to talk about an action or actions that started in the past and continued until recently or that
continue into the future:
The present perfect continuous is often used with 'since', 'for', 'all week', 'for days','lately', 'recently', 'over the last
few months'.

We can use it to refer to an action that has finished but
you can still see evidence.
 you have got a a stiff neck. You have been
working too long on computer.
 You look tired. Have you been sleeping properly?
It can refer to an action that has not finished.
 Dr X has been treating Mr. Smith at this hospital
for 3 years.

It can refer to a series of actions.

 She's been taking her medication regularly for a couple of years.

Question: has / have + Subject + been + a verb + ing? Negative: has / have + not + been + a verb + ing
 Has He been treating here since 2001?  He has not been treating here since 2001..

Passive: No

Three common ways to form present perfect when writing referral letters are as follows:

Present Perfect Simple Present Perfect Progressive Present Perfect Passive

Form: have/has+ past participle
 I have treated Mr. Smith at
this hospital for 3 years.
 Dr X has treated Mr. Smith at
this hospital for 3 years.
Form: have/has+been+____ing
(present participle).
 I have been treating Mr. Smith at
this hospital for 3 years.
 Dr X has been treating Mr. Smith
at this hospital for 3 years.
Form: have/has +been+ past
Participle
 Mr. Smith has been treated at
this hospital for 3 years(..by Dr X).
 They have been treated at this
hospital for 3 years(..byDr X).
 Use Present perfect with : for ,since and Over
For )‫)حوالي‬
For is used to describe a period of
time specific time or time frame
statements has / have + past participle of a
verb + For + time of period
The patient has been in pain for 5
hours. (recent past)
The patient has been waiting for 15
minutes. (recent past)
He has been complaining of back
pain for a week. (recent past)
The patient has been on this
medication for 6 months.
I have been treating the patient for
3 years (distant past)
He has been a smoker for a period
of 25 years. (distant past)
negative has / have + not + past participle
of a verb + For + time of period
I haven’t seen the patient for 1 year.
He has not had bowel
motions for 3 days.
object + (has been/have been) +
Passive past participle + for time of period
Aspirin has been taken daily for a
period of one year.
Common Time Markers
For
5 hours
15 minutes
a week
a long time
3 days
ages
the past 10 years
Since )‫) منذ‬
Since is used to state the start of a similar time markers to for but is
period ‫ و‬means start point in time
has / have + past participle of a verb has / have + past participle of a verb
+ since + start point in time
The patient has been in pain since
10am. (recent past)
The patient has been waiting since
11.45am. (recent past)
He has been complaining of back pain condition)
since last week. (recent past)
The patient has been on this
medication since January
I have been treating the patient since
2005. (distant past)
He has been a smoker since 1990.
(distant past)
has / have + not + past participle of
a verb + since start point in time
I haven’t seen this patient since
December 2007
He has not had bowel
motions since Saturday.
object + (has been/have been) + P
participle + since start point in time
Aspirin has been taken daily since
2012.
6 o’clock
the patient became ill
March
Wednesday
2001
12 June
this morning
Over )‫)طوال او خالل‬
used to express a change in
condition, or a repeated event.
(means during this a time(
+ over + time of period
The patient's condition has
deteriorated over the past 3
months.(change in condition)
The patient's back pain has worsened
over the last week.(change in
The patient has presented several
times over the last year. (repeated
event)
He has tried to quit smoking several
times over the past 25
years.(repeated event)
has / have + not + past participle of
a verb + over time period
The patient has not taken aspirin
regularly over the past 25 yrs.
object + (has been/have been) +
past participle + over time period
Aspirin has been taken irregularly
over the past 25 yrs.
Since
Common Mistakes
Incorrect
The patient diagnosed with hypothyroidism since 2007
Explanation:
You cannot use simple present grammar with for or
since.
She has been problems with arthritis in her hands.
Explanation:
Problems in this sentence is a noun so you can not use
“been” with a noun.
You must use present perfect cont. as :
 have / has + been + ___ing verb + noun
Or present perfect + noun or adjective
 have or has + past participle + noun
 have or has + past participle + adjective
He smokes 2 packs of cigarettes a day for the past 25 –
30 years.
Over the past week she remains free from severe pain
and has been able to tolerate a fluid diet.
Also, there is an ulcer on the right lower lateral border
of the tongue, which is present for more than one year.
Mr. Lee is a patient of mine since 2000
Mr. Eddy is a known smoker for 25-30 years.
The verbs in these sentences are in simple present
tense. Present perfect needs to be used because you
are referring to a time period which started in the past
and has continued to the present.
In these situations you must use present perfect tense.
This disease is occurred as a complication following
mumps
Mrs. Brown has been presenting to me on several
occasions over the past few months.
Explanation: Progressive form not required.
She has underwent triple coronary bypass
surgery on 10/08/15
Correct
The patient was diagnosed with hyperthyroidism in 2007
(simple past)
The patient has had hyperthyroidism since 2007
(present perfect)
She has been having problems with arthritis in her hands .
(present perfect cont.)
She has had problems with arthritis in her hands.
(present perfect)
She has been hypertensive since 2007.
(present perfect + adjective)
She has had hypertension since 2007.
(present perfect + noun)
He has smoked two packs of cigarettes a day for the past
25-30 years. (present perfect)
Over the past week she has remained free from severe
pain and has been able to tolerate a fluid diet.
(present perfect)
Also, there is an ulcer on the right lower lateral border of
the tongue, which has been present for more than one
year. (present perfect)
Mr Lee has been a patient of mine since 2000.
Mr. Eddy has been a smoker for 25 years
(present perfect )
This disease has occurred as a complication following
mumps (present perfect )
Mrs. Brown has presented to me on several occasions
over the past few months. (present perfect )
She underwent triple coronary bypass surgery on
10/08/15
Present perfect or Present perfect continuous
Often there is very little difference between the present perfect simple and the present perfect
continuous.
In many cases, both are equally acceptable.
• They've been treating here for a long time but Andy has treated here for even longer.
To emphasize the action, we use the continuous form.
• Andy look well, She has been taking aspirin daily.

To emphasize the result of the action, we use the simple form.

• Andy has got better with drugs, she's written a very good report.

When an action is finished and you can see the results, use the continuous form.
• you look well . You've been taking aspirin daily, haven't you?
• You look tired . Have you been sleeping well ?

When you use the words 'ever' or 'never', use the simple form.
• I don't know him. I've never treated him.
• Have you ever treated Down syndrome patient ?
Simple Past Tense:
We use the past simple to talk about actions and states which we see as completed in the past.
We can use it to talk about a specific point in time. used with last, ago, yesterday , in 1988 AD

. ‫ مع مالحظة األفعال الشاذة‬ed ‫يتكون هذا الزمن من التصريف الثاني للفعل أي إضافة‬
We use the simple past tense when:
 the event is in the past and the event is completely finished
 we say (or understand) the time and/or place of the event.

In general, if we say the time or place of the event, must use the simple past; we cannot use the present perfect.

We can use it to talk about completed action at a specific It can also be used to talk about completed condition at
point in time. a period of time.
 He first came to see me in 2012.  Mrs. Kelly had diverticulitis when she was a teenager.
 The patient stopped taking medication yesterday.  The patient was diagnosed with cancer 3 months ago.

Question :
Negative:
auxiliary verb did + Subject + present verb + object.
auxiliary verb did + not (didn't) + present verb + object:
 dose she respond to treatment?
 The patient didn’t respond to treatment.
Yes, she dose ……/ No, she dose not.

with verb Be : Passive:

Subject + verb be + object (not use auxiliary verb) object + (was/ were) + past participle
Positive : A colostomy was performed  Aspirin was taken daily. (passive)
Negative : A colostomy was not performed yesterday.
Question : Was a colostomy performed Yesterday?

The past form for all regular verbs ends in –ed , The past form for all irregular verbs is variable..
If single syllable verbs ending with vowel and single consonant, double final consonant and added ed .
 Slip = slipped ,..Drop= dropped ,…Cross= crossed
If verbs ending with E, only added e. dance = danced ,…. live= lived ,….race = raced

If verb ends with ( y )and before the (y) is a consonant letter , we directly omit the (y) and add (ied):
 Study = studied ,…Try = tried ,..Dry= dried

if before the (y) is a vowel letter we directly add (ed): ,..Play = played ,…Pray = prayed ,..Stay = stayed.
Present Perfect or Past Simple?
There is often confusion of whether to use simple past or present perfect tense.
The basic rule to remember is :
if you are referring a particular time in the past then you must use simple past tense.
If you are referring to a period of time that has continued up to now use present perfect tense.
If you are referring two events which are both in the past compared to the time of speaking or
writing, then the event furthest in the past is described using the past perfect. The event more
recently in the past is described using simple past.

There are some common time markers used with simple past and present perfect.
It is important to study, learn and use these tenses correctly when writing referral letters as you
must refer to both past events and periods of time leading to the present.

Time markers with Simple past Time markers with Present perfect
 until he was 5  for
 when she was a teenager  for the last 12 years
 in 2004  since
 yet (for negetive)
 ... ago
 up to now /until now / till now/ so far
 Yesterday  lately / recently
 On September 9
1. He sucked his thumb until he was 5. 1. He has been sucking his thumb for five
2. Mrs. Kelly had diverticulitis when she years.
was a teenager. 2. Mrs. Kelly has had diverticulitis for the
3. He first came to see me in 2004. last 12 years
4. The patient didn’t respond to 3. He has been seeing me since 2004.
treatment. 4. The patient hasn’t responded to
5. The patient was diagnosed with cancer treatment yet.
3 months ago. 5. The patient has shown no signs of
6. The patient stopped taking medication improvement up to now.
yesterday. 6. The patient has stopped taking
medication recently.
Past Continuous Tense: was / were + verb + ing

We use the past continuous to talk about past events which went on for a period of time.

Used with…… because ,as ,while , when

It is come with Simple Past Tense (long Past Continuous Tense then short Simple Past Tense)

To emphasize the continuing process of an activity or We often use it to describe a "background action" when
the period of that activity in past. something else happened.
 The patient was taking aspirin daily.  He was watching TV when developed a seizure.

To discussed something that happened in middle of To discussed something that continue to happen for
something else long time
 While, I was sleeping my head was hurting.  he was complaining all night.

Question : be verb + Subject + ___ing ? Negative:

 was the patient taking aspirin daily? Subject + was / were + not + ___ing (present participle)
Yes, she was ……/ No, she was not.  The patient was not taking aspirin daily.

Passive: Subject + was / were + being + ___ing (present participle)

 The Aspirin was being taken daily
Past Perfect Tense : had + past participle

We use the past perfect simple to talk about what happened before a point in the past.
looks back from a point in the past to further in the past. use with as soon as, before , after, which, because

Past Perfect is an important tense in referral letters.

The main functions of this tense are describe a past event or actions that began before another event in the past.
When used with simple past it allows the writer to distinguish the order of events:
The past perfect is often used reported speech (what people had Said / thought/ believed)
The case notes may describe the patient's condition at a time in the past, i.e patient found blood in toilet bowl 2 times. Thi
written in the referral letter as follows:
At today’s consultation, Ms. Leon reported that there had been blood in the toilet bowl on 2 occasions
describe a past event or condition completed before In reported speech
another event in past  today, Ms. Leon reported that there had been
 She had not been able to conceive over the blood in the toilet bowl on 2 occasions.
previous four months and as a result she was
suffering from depression.
 The patient had taken aspirin daily for a period of
one year.

Question : had + Subject + past participle ? Negative: had + not + past participle
 had Rose suffering abdominal pain before she  she had not suffering abdominal pain before she
vomited ? Yes, she had ……/ No, she had not. vomited.

Passive: object + had + been+ past participle

 Aspirin had been taken daily for a period of one year.

Handy Hint :
do not use past perfect when describing one past event as it is not necessary.
perfect is often used with the word previous instead of ago to demonstrate that you are referring to a time before a
particular date in the past, not the date you are writing the letter.
Compare
 The patient had been feeling unwell last week.(incorrect if 1 past event described)
 The patient was feeling unwell last week. (correct)
 The patient had been feeling unwell last week and was admitted to hospital for observation. (correct as 2 past
events need to be distinguished)
Past Perfect Continuous Tense : Had + been + ___ ing (present participle)
It designates action which occur in the past and complete before another past action .

use with ….For, before , when ,until, because.

We use the past perfect continuous to look back at a We use it when reporting things said in the past.
situation in progress.  Ms. Leon reported that there had been bleeding
 The patient had been taking aspirin before he in the toilet bowl .
changed drugs.

It discussed that something happened because of what

We use it to say what had been happening before
happened in past .
something else happened.
 He was out of breath when he arrived because he
 She had been playing tennis for only a few
had been smoking for 20 years.
minutes when she broken her arm.

Question : had + Subject + been + ___ ing ? Negative: had + not + been + ___ ing .
 had I been gain weight because I not sleeping well ?  I gain weight because I had not been sleeping well.
 had I been so tired because I was not exercising?  I was so tired because I had not been exercising.

Passive: No
Common mistakes
Incorrect Correct
 She presented to me on 03/07/2015 for a regular  She presented to me on 03/07/2015 for a regular
check up because she experienced several episode of checkup because she had experienced several
heart flutter over the past few weeks. episodes of heart flutter over the previous few
weeks.
Past perfect tense is necessary here (had experienced)
to differentiate what happened prior to the check up,
which is also in the past.
As your meaning is prior to 03/07/105and not the day
of writing the letter, you should use the word previous
instead of past.

 On review two weeks later, the frequency of  On review two weeks later, the frequency
headache decreased. of headache had decreased.

Use past perfect to indicate that frequency of

headache had decreased prior to the consultation.

 A review on 25/04/15 showed the patient’s general  A review on 25/04/15 showed the patient’s
health improved and her blood pressure dropped to general health had improved and her blood
140/85 and she lost 4 kg. pressure had dropped to 140/85 and she had lost
4kg.
Past perfect is used when describing a condition
that was true at a certain time in the past.
 She presented to me yesterday evening with  She presented to me yesterday evening with
abdominal pain, mostly on the left iliac fossa, and abdominal pain, mostly on the left iliac fossa,
was since 24 hours. which had been occurring for the previous 24
hours.
Note that in the correct version 3 different times
need to be considered
1. The present i. e today: time of writing
2. Yesterday evenings consultation
3. Symptoms which occurred before yesterday's
consultation.
 She was admitted to Royal Brisbane and Women’s  She was admitted to Royal Brisbane and
Hospital on 24/07/15 because she collapsed at home. Women’s Hospital on 24/07/15 because she had
collapsed at home.
Use past perfect tense to create a time line, so
past perfect indicates the collapse occurred before the Active voice is preferred here as the patient is the
admission. subject.
 Initially she presented to me in July 2015 with a
complaint of chest discomfort for three weeks.
If you use this time expression: for a few weeks then
you must either use a relative clause
and past perfect verb tense, or the very concise
and useful expression: of______duration.
 Mrs. Jones had taken Microgynon 30 for the previous
5 years but had stopped in May 2015.
There is no need to use past perfect twice.
 On rechecking at 10.45pm, her condition has further
deteriorated and an ambulance was arranged for
transfer to hospital.
Use past perfect and simple past together to
distinguish the order of events i.e her condition
deteriorated then an ambulance was called.
 Initially she presented to me in July 2015 with a
complaint of chest discomfort which had been
present for three weeks.
 Initially she presented to me in July 2006 with a
complaint of chest discomfort of 3 week
duration.
 Mrs. Jones had taken Microgynon 30 for the
previous 5 years but stopped in May 2015.
 On rechecking at 10.45pm, her condition had
further deteriorated and an ambulance was
arranged for transfer to hospital.
Active & Passive verbs:
The passive voice is commonly used in technical and formal writing.
Using active verbs is good when you wish to create a personal tone or impart subjective
information ,However, passive verbs and sentence structure enables the writer to focus attention
on what is most important in a sentence such as procedures or medications.
Compare
In the active voice, the subject is the ‘doer’ of the action e.g.
1. I advised the patient to stop smoking.
2. I advised her to do bed exercises to prevent further complications such as deep vein t
3. You need to take Flucloxacillin capsules twice a day for a duration of 2 weeks.
4. The doctor took the patient’s temperature at 10 pm.
In the passive voice, the ‘doer’ is not important but attention is drawn to the person or thing acted
upone .g.
1. The patient was advised to stop smoking (focus on the patient)
2. Bed exercises were advised to prevent further complications such as deep vein t.
(focus on the treatment)
3. You need to take Flucloxacillin capsules twice a day for a duration of 2 weeks.
4. The patient’s temperature was taken at 10 pm.

Correct use of passive forms contributes to your scores for Appropriateness of Language as well as
Linguistic Features.

On initial presentation in January 2014 Mr Gilbert [report] persistent discomfort in his knee despite
taking NSAIDs and oxycodone for pain relief and undergoing regular physiotherapy. He [refer] to a
physiotherapist for a knee brace, but this [have] little effect on his condition.

Following his meniscal cartilage injury, Mr Gilbert [begin] a weight loss programme and now [weigh]
88 kilogrammes. I strongly [recommend] further weight loss to reduce knee strain.
 To form the passive, use :the be verb (be, is/ are; was/were; has been/have been) + past participle

Active Passive
Present simple Present simple
 The patient takes aspirin daily.  Aspirin is taken daily.
Present simple continuous Present simple continuous
 The patient is taking aspirin daily.  Aspirin is being taken daily.
Past simple Past simple
 The patient took aspirin daily.  Aspirin was taken daily.
Past simple continuous Past simple continuous
 The patient was taking aspirin daily.  Aspirin was being taken daily.
Present perfect Present perfect
 The patient has taken aspirin, noten and  Aspirin, noten and normison have been taken for a
normison for a period of one year. period of one year.
Present perfect continuous Present perfect continuous
 The patient has been taking aspirin daily.  Nil
Past perfect Past perfect
 The patient had taken aspirin daily for a period of  Aspirin had been taken daily for a period of one year.
one year.  Aspirin, noten and normison had been taken for a
 The patient had taken aspirin, noten and period of one year.
normison for a period of one year.
Past perfect continuous Past perfect continuous
 The patient had been taking aspirin daily.  Nil
Future / simple form Future / simple form
 I think the patient will take aspirin in the evening  aspirin will be taken in the evening.
Future / continuous form Future / continuous form
 This time tomorrow, the patient will be taking  Aspirin will be taken this time tomorrow.
aspirin

Future / Perfect Future / Perfect

 By tomorrow evening, the patient will have
finished his aspirin .
Modal form / Perfect infinitive form
 The patient should have taken aspirin in the
evening.
 By tomorrow evening, aspirin will have been finished.
Modal form / Perfect infinitive form
 Aspirin should have been taken in the evening.
Common mistakes
Incorrect
 She was performed a colostomy accompanied with a
partial bowel resection.
 As per the doctor’s order, we were organized daily
home visits.
 On 9.7.06 he was presented to me for his regular
check up.
 On the subsequent visit the treatment options was
discussed .
 She had done colonoscopy 3 years ago.
 Initially, she came to me on 14/01/2006 for a general
check up and was found her blood pressure 160/90.
 In addition, her baby will need to monitor his growth
and general health condition
Correct
 A colostomy was performed with a partial bowel
resection.
 A colostomy was performed on the patient by the
doctor with a partial bowel resection.
The first example is better as it more concise and
also it is obvious the roles of patient and doctor so
it is unnecessary to state them.
 As per the doctor’s order, daily home visits were
organized. (passive)
 As per the doctor’s order, we organised daily home
visits. (active)
Both sentences are grammatically correct but the
first example is preferred because it focuses
attention on the procedure.
 On 9.7.06 he presented to me for his regular check
up.
Active voice is preferred here as the patient is the
subject.
 On the subsequent visit the treatment options
were discussed.
Because the noun is plural the plural verb “were”
is required.
 A colonoscopy was done 3 years ago.
 She had a colonoscopy done 3 years ago.
In these sentences it is unimportant who
performed the colonoscopy so passive voice is
used.
 Initially, she came to me on 14/01/2006 for a
general check up and her blood pressure was
found to be 160/90.
After the conjunction and a subject is required.
 In addition, the baby’s growth and general health
condition will need to be monitored
Infinitive form of the passive.
Past Perfect & Reported Speech
Two common tenses that need to be mastered in OET are past perfect and reported speech.
They are used frequently used together it is often necessary to report what a patient said or how
they felt some time in the past. This is because often the case notes describe a long history of
condition, treatments & medications. In order to express this logically and clearly it is necessary to
show clearly the order in which these health events occurred.
Past perfect and reported speech, in combination with time markers, can help you do this.
Incorrect Correct

She presented to me on 03/07/2006 for a She presented to me on 03/07/2006 for a

regular check up because she experienced regular check up because she had
several episode of heart flutter over the past experienced several episodes of heart flutter
few weeks over the previous few weeks (past perfect)
There are two mistakes in the sentence
above which could confuse the reader.
1. Past perfect tense is necessary here
(had experienced) to differentiate
what happened prior to the check up,
which is also in the past.
2. As your meaning is prior to 3/7/09 and not
the day of writing the letter, you should use
the word previous instead of past.
On review two weeks later, the frequency On review two weeks later, the frequency had
decreased. decreased. (past perfect)
Use past perfect to indicate frequency of
attacks had decreased prior to consultation
A review on 25/04/06 showed the patient’s general A review on 25/04/06 showed the patient’s general
health improved and her blood pressure dropped to health had improved and her blood pressure had
140/85 and she lost 4 kg. dropped to 140/85 and she had lost 4kg. (past
Past perfect is used when describing a condition perfect)
that was true at a certain time in the past.

At today’s consultation, Ms. Leon reported At today’s consultation, Ms. Leon reported
blood in the toilet bowl on 2 occasions. that there had been blood in the toilet bowl on
The intended meaning of the writer in this 2 occasions.
sentence is not achieved. This sentence could be
taken to mean that Ms. Leon made 2 reports of (reporting verb + that)(past perfect)
blood in the toilet bowl. To make the meaning
clearer it is necessary to use a reporting verb +
that. Common reporting verbs include: say,
report, explain, complain, request, insist:
e.g. The patient complained that the pain had
been severe for 6 hours.
She presented to me yesterday evening with
abdominal pain, mostly on the left iliac
fossa, and was since 24 hours.
The meaning is unclear because the order
and timing of events is not clearly expressed.
She presented to me yesterday evening
with abdominal pain, mostly on the left
iliac fossa, which had been occurring for the
previous 24 hours. (past perfect cont.)

She was admitted in Royal Brisbane and She was admitted in Royal Brisbane and
Women’s Hospital on 24/07/08 because she Women’s Hospital on 24/07/08 because she
collapsed at home. had collapsed at home. (past perfect)

Use past perfect tense to create a time line,

as you used admitted before, so past perfect
indicates the collapse was before the
admission.

She has recently been hospitalized for 9 days She was recently hospitalized for 9 days
after she had collapsed at home, after she had collapsed at home,
accompanied by dehydration, nausea and accompanied by dehydration, nausea and
severe pain at her unit. severe pain at her unit.

Past perfect should be used with simple past, (simple pas + past perfect)
(not present perfect as above sentence) to
indicate clearly the order of events.

Initially she presented to me in July 2006 Initially she presented to me in July 2006
with a complaint of chest discomfort for few with a complaint of chest discomfort which
weeks. had been occurring for a few weeks.

If you use this time expression: for a few (past perfect cont.)
weeks then you must use either present
perfect or past perfect verb tense: ….chest
discomfort which had been occurring for a
few weeks.
Subject-Verb Agreement
Subject verb agreement is an area where accuracy is important.
Below are some important rules which you should remember.

Singular subject & verb Plural subject & verb Explanation

 The suture has been removed.
 One of the medications is
unavailable.
 The sutures have been removed.
 All of the medications are
unavailable.
 The verb agrees with the subject
which is this case is either singular in
one or plural in all.

 The verb agrees with the subject

 One of the medications has side  All of the medications have side which is this case is either singular in
effects. effects one or plural in all.

 Mrs. Pratt lives in rental  Mr. & Mrs. Pratt live in rental
accommodation. accommodation
Common mistakes
Incorrect Correct
 Alison’s school medical record reveals  Alison’s school medical record reveals
that her attendance have been declining that her attendance hasbeen declining
in recent past. in recent past.

 All these findings has been confirmed  All these findings have been confirmed
with bitewing radiographs. with bite-wing radiographs.

 I am writing to refer this patient who I • I am writing to refer this patient who I suspect
suspect is suffering from rheumatic fever and is suffering from rheumatic fever and needs
need urgent admission. urgent admission

 I believe that the teeth 65 and 54 needs to  I believe that the teeth 65 and 54 need to be
be extracted followed by space maintainer. extracted followed by space maintainer.

 Threadworms looks like fine pieces of cotton  Threadworms look like fine pieces of cotton thread
thread that can grow up to 1.5 cm long. that can grow up to 1.5 cm long.
 A threadworm looks like fine pieces of cotton
thread that can grow up to 1.5 cm long.
Future Simple will : will do/ going to

There is no one 'future tense' in English. There are 4 future forms.

 'will' is the one which is used most often in formal English,.
 'going to' is the one which is used most often in spoken English.

With will/won't — Activity or event that will or won't exist or happen in the future
With going to /— Used for future in relation to circumstances in the present

Use with ….tomorrow , next , in the future :

Future Simple: will do/ subject + will + present verb

Talk about future events we believe to be certain. Often we add 'perhaps', 'maybe', 'probably', 'possibly' .
• The sun will rise over there tomorrow morning. • I'll probably come back later.

We use 'will' at the moment we make a new decision or

We often use 'will' with 'I think' or 'I hope'
plan. The thought has just come into our head.
 I think he will takes Aspirin.
 I'll answer that.
Question : Will + subject + present verb ?
Negative: subject + won't + present verb
 Is the patient will take Aspirin?....
• I think the patient won't take Aspirin.
Yes, he is. ….No, he is not.
Passive: object + will + be + past participle
 The patient will take Aspirin in the evening. (Active)  Aspirin will be taken in the evening. (Passive)

Future Simple: going to/subject + going to + present verb

Positive : subject + be + going to + present verb. Passive: object + be + going to
 The patient is going to take Aspirin in the evening • Aspirin is going to be taken in the evening

Question : be + subject + going to + present verb? Negative: subject + be + not + going to + present verb
• Is the patient is going to take Aspirin ? (yes or no )  the patient is not going to take Aspirin.
Future Continuous Tense: Will be doing /going to be
Used to be' to talk about something that will be in progress at particular moment in the future.
Used with :at , by , in , from, to, all, after , at this very moment , this time next week/…next month/….next year.

Use to talk about something that will be in progress at particular moment in the future.
• This time next week, I'll be sitting on the beach in Barbados.
• This time next week, I am going to be sitting on the beach in Barbados.

Use to talk about future events that are fixed or decided.

• He'll be looking after the patient until we can appoint a nursing home care.
• He is going to be looking after the patient until we can appoint a nursing home care.

Use to predict what is happening now.

• They'll be deciding who gets the contract at this very moment. I'm very nervous.
• They are going to be deciding who gets the contract at this very moment. I'm very nervous.

Use ' to ask extremely politely, and with no pressure, about future plans.
• Will you be eating with us this evening?
• Are you going to eating with us this evening?

Will be doing / will + present verb + __ing . Going to be / going to + be + present verb ----ing

Positive: Subject + Will + be + ___ ing .

Positive: Subject + going to + be +__ing.
 This time tomorrow, the patient will be stop taking
 This time tomorrow, the patient is going to be taking
aspirin
aspirin .

Negative: Subject + Will + not + be + ___ ing . Negative: Subject + not + going to + be + ___ ing
 The patient will not be taking aspirin by evening.  The patient is not going to be taking aspirin by
evening.

Question: Will + Subject + be + ___ ing ? Question: be + Subject + going to + be + ___ ing ?
 Will the patient be taking aspirin at this moment  Is the patient going to be taking aspirin at this
tomorrow? Yes , he will be. ….No, he will be not. moment tomorrow? Yes , he Yes he is. …No, he is not.

Passive: object + will + be + past participle Passive: object + going to +be + past participle
 This time tomorrow, aspirin will be taken .  This time tomorrow, aspirin is going to be taken .
Future Perfect Tense: will have done/ will + have + past participle
Used to expected some events before other events in future
Used with :at , by , in , from, to, all, after

We can use 'will have done' to talk about what will have been achieved by a certain moment in time.
• I'll have finished my tablet by Friday.
If we want to emphasise the continuity of the activity, we can use the continuous form.
• She'll have been in coma for more than two hours straight by the time she gets ER.
We can also use 'will have done' to predict what we think has already happened at present.
• She'll have entered her operation by now . It's too late to see her.
• They'll have scanned by now. We should wait the result today or tomorrow.
Positive: Will + have + past participle.
 The patient will have stopped aspirin before operation a next week.
 The patient will have finished his chemotherapy cycle by the time he turn 5.
 The patient will have suffered gastric ache when he stop taking antacid.

Negative: Will + have + not + past participle

 The patient will have not finished 2 weeks aspirin course by next visit.

Question: Will + have + past participle?

 Will the patient have stop taken aspirin before operation ? Yes, he will have. …. No, he will have not.

Passive: Object + will + have been + past participle

 By next visit, Aspirin will have been stopped .

Future Perfect Continuous: will have been doing / will + have + been + __ ing
Used to express about a time that will spend in specific time in future
Used with : at , by , in , when, all, because

Positive: Will + have + been + __ ing.

 By next visit, the patient will have been taking Aspirin for 12 months.

Negative: Will + have + not + been +__ ing

 By next visit, the patient will have not been taking aspirin for 12 months.

Question: Will + have + been + __ ing?

 Will the patient have been taking aspirin for 2 weeks by next visit?
Yes, he will have been. ……. No, he will have not been.
Modals

Modal verbs (Can, could, may, might, must, will, shall, should and would etc.)
These are used to talk about things which we expect, which are possible, which we think are necessary
or which we are not sure about e.g. It is suspected that she may be suffering concussion.
Rule
Use infinitive post modal ex :-
 you can eat
 you should drink
 you cannot eat
 She might not know
Use modal with verb to be ex:- To be + adjective
 you must be careful
 you should be a ware
 You might interested

Could
 use for ability in past = Last week I could walk to the shops and back but this week I cant.
 Polite request = Could you please take a care about this patient
 Possibility = you could take a table at the morning or evening
 Suggestion = you could wearing a sling to support your arm.

Should have
 We can use 'should have' to talk about past events that did not happen.
• I should have let her know what was happening but I forgot.
 We can also use 'should have' to speculate about events that may or may not have
• He should have arrived at his office by now. Let's try ringing him.
 We can use ' should not have' to speculate negatively what may or may not have happened.
• She shouldn't have left work yet. I'll call her office.
 We can also use 'should not have' to regret past actions.
• I shouldn't have shouted at you. I apologise.

Polite request
 Could you please take a care about this patient
 Would you please take a care about this patient
 It would be beneficial if you could …
Can have / Could have
 We can use 'could have' to talk about something somebody was capable of doing but didn't do.
• I could have gone to Oxford University but I preferred Harvard.
 Often, there is a sense of criticism.
• You could have phoned me to let me know
 We can use 'couldn't have' to talk about something we were not capable of doing.
• I couldn't have managed without you.
 We can use 'could have' to speculate about what has happened. (We can also use 'may have' or
'might have' in these situations.)
• She could have taken the earlier train.
 We can also use 'can have' to speculate about what has happened but only in questions and
negative sentences and with words such as 'hardly', 'never' and 'only'.
• Can she have forgotten about our meeting?
 We can also use 'could have' to speculate about something that didn't happen.
• You could have broken your neck, jumping out the window like that.
 can also use 'could have' to talk about present situations that have not happened.
• I could have been earning a lot as an accountant but the work was just too boring.

Modal form / Perfect infinitive form - Active Modal form / Perfect infinitive form - passive
 The patient should have taken aspirin in the evening.  Aspirin should have been taken in the evening.

ANSWER
1. We expect that the patient will Make a full recovery.
2. It may be necessary to keep him in isolation.
3. I am not sure whether these drugs might do more harm than good.
4. If the wound is not cleaned properly, it could get infected.
5. It might have been a good idea to have kept him in hospital longer.
Prepositions
Prepositions are a difficult area of language to fully master as their usage is not
governed by strict rules. The best way to learn prepositions is by regular reading so that
you can slowly absorb and become comfortable with their correct use. However, it is
possible to memorise the correct use of a selection of prepositions in order to use them
accurately in writing the referral letter.
A preposition shows the relation between the subject and the object.
There are also prepositions of time and prepositions of place.

Prepositions of Time
In: In is used for longer On: On is used for days At: At is used for the Some words require no
periods of time with and dates and sometime time of day(noon, preposition
months, with years, with expressions night, midnight) and
seasons: for some expressions
 In November  On Monday  At 6 o'clock  Yesterday
 In Spring  On 20 November  At night  Today
 In 2006  On Christmas day  At lunchtime  Tomorrow
 In the past  On his birthday  At that time  Last week
 In the future  On review  At the moment  This week
 In the morning  On examination  At the age of 45  Next week
 In the afternoon  On investigation  At birth
 In her childhood  On presentation
 In his twenties  On two occasions

Prepositions of Place
In: In is used for inside of something On: is used for the surface At: At is used for a place of activity
area of something
 In Australia  On the skin  At home
 In hospital  On the ground  At work
 In surgery floor  At the wound site
 In the stomach  At the clinic
 Common Errors
Incorrect Correct
 His father died of cancer during the age of 50.  His father died of cancer at the age of 50.

 In examination today, the patient was anxious  On examination today, the patient was
and distressed. anxious and distressed.

 Initial examination on today revealed  Initial examination today revealed

inflammed gums. inflammed gums.

 On December 2006, the patient had his  In December 2006, the patient had his
wisdom teeth removed. wisdom teeth removed.

 The patient's family arrived at Australia in last  The patient's family arrived in Australia last
year. year.
Useful phrases

Introductory sentence:
 I am referring Tim back into your care for full assessment of his recurring headaches.
 I am writing to request
 I am writing with regards to
 I am writing to inform you about

The Request
 I would appreciate your assessment and advice regarding this.
 I will be in touch to follow his progress.
 Based on my provisional diagnosis
 His condition continued to deteriorate
 His blood tests revealed
 On examination, he looked ….

Patient reports
 The symptoms were not related to her previous condition.
 The patient will not be capable of any heavy lifting in the future.
 I am pleased with the patient’s progress so far –it’s better than expected.
 A copy of the patient’s medical history is attached to this letter
 The patient was not accustomed to hospital routine –it was her first admission.
 She is serious about losing weight and getting fit to improve her quality of life.

Reporting verbs
 You can usually replace ‘said’ with a far more descriptive verb which gives the reader or listener
information about how the speaker was feeling at the time.
 Good alternatives for the referral letter are: complained, mentioned, stated, demanded, explained.

Example sentences
 ‘ Sally complained she had been kept waiting for more than 1 hour.’
 ‘ James’ mother mentioned he is not sleeping as well as normally’
ADMITTED
Admitted is a very common medical verb to explain a patient will need stay in hospital.
The meaning changes depending on the preposition that comes with it.
 admitted with symptoms
 admitted to hospital
 admitted on Tuesday
 admitted for surgery
 admitted by the doctor in charge
 admitted in pain
 admitted after an accident

hint
verb + with = admitted with , diagnosed with ,consistent with, transferred with
verb /noun + on = advice on, indicative on
verb /noun + of = diagnosis of, evidence of, suspicious of , with a complaint of
verb /noun + to = allergic to, reluctant to, present to, advised to
verb /noun + from = suffering from
verb + for = refer for
verb /noun + by
verb + toward
 Phrasal Verbs and Preposition
A to Z of Phrasal Verbs and Useful Vocabulary
Letter Expression Example sentence
a.  admitted to  The patient was admitted to our hospital in March 2008 for the first
time.

 associated with  Mr. Booth first came to see me on 12/08/08 complaining of shortness
of breath which was worse when he was lying down. It was
associated with a tightness in the chest and coughing.

 advised to  She was advised to return the next day for a blood test and follow up
consultation. (verb)

 advice on  For both children advice on recommended vaccines will be

necessary. (noun)
 allergies
 She is not on any medication and has no known allergies.
 allergic to
 Please note, the patient is allergic to penicillin.
 arrived at  The patient arrived at my surgery in a depressed state.
 arrived in
 The family arrived in Australia in 2007

b.  believe  I believe the patient needs urgent assessment and hospital admission

 borderline  She was noted to be overweight and has borderline hypertension.

c.  consistent with  I am writing to refer Mr. Walker a 40 year old married patient,
presenting with signs and symptoms consistent with prostatic
enlargement.
 commence  IV fluids were commenced in order to improve hydration.

 commence on  Therefore I commenced him on omeprazol 20 mg daily and strongly

advised him to stop smoking cigarettes and stop drinking alcohol.
(active)
  She was commenced on 15gram alepam 1 tablet nightly for her
current anxiety and sleeplessness. (passive)
 confidence in
 She lacks confidence in caring her baby in terms of breast feeding and
bathing.

d.  discharge on  He will be discharged on the 12th of August.

 deteriorate  Since 28th of July her condition has deteriorated with occasional
disorientation.
 deny  She denied vomiting and she was vague reporting about laxatives.

 difficulty in  Mr. MacIntosh presented to me with the complaint of difficulty in

passing urine.
 diagnosed with  I am writing to refer my patient, Fletcher, a nine year old Labrador
cross dog who is diagnosed with high grade lymphoma. (verb)

 diagnosis of  Histological results confirmed the diagnosis of high grade

lymphoma.(noun)
e.  evidence of  Examination findings revealed evidence of an enlarged prostate.

 enclosed  I have enclosed the radiograph for your convenience.

f.  to follow  The patient was advised to follow a low fat diet.

h.  history  The patient first attended me yesterday evening with a one day
history of lower abdominal pain
 Mr. Abrahim has a positive family history of prostate cancer
i.  indicate  The family has indicated that they need an interpreter who speaks
Farsi or Arabic during follow-up visits with this family.

 indicative on  However, there was slight swelling in the right groin indicative of
inguinal hernia
 inconspicuous
 His family and social history is inconspicious.
k.  known  She is a known asthmatic since childhood and is on Budesonide
inhaler for the same.
m.  to make an  I have made an appointment for her through your receptionist.
 appointment
n.  on examination  On examination, her blood pressure was 180/90 mm Hg with a
regular pulse of 70 beats per minute.
o.  occasions  Today she presented very anxious and depressed as she had noted
some blood in her motions on two separate occasions.
p.  provisional  Provisional diagnosis suggests prostate cancer.

 present at  Mr Gates presented at my clinic yesterday at 7pm with a complaint of

lower back pain.
 present to  Today, he presented to me complaining of a regular dull ache in the
groin.
q.  queries  If you have any further queries, please do not hesitate to contact me.

r.  reveal  Examination today revealed a significantly increased right groin

swelling.
 risk factors  His risk factors include: smoking 20 cigarettes per day, lack of exercise
and a strong family history of hypertension.

 a routine  He has made a routine recovery and his wounds appear to be healing
recovery well.

 reluctant to  He is reluctant to seek treatment.

 rule out  I believe she needs an urgent assessment to rule out bipolar disorder

 remarkable  There were no other remarkable findings.

findings
s.  suggestive of  Miss Jones is suffering from the signs and symptoms suggestive of
ectopic pregnancy.

 suspicious of  I am writing to refer this patient, a 60-year-old women,with

symptoms suspicious of bowel malignancy

 suffering from  Ms.Tylor has been suffering from diabetes and she is administering
insulin injection by herself.
 signs and  He is a 40-year-old man who is suffering from signs and symptoms
symptoms suggestive of peritonitis with perforated gastric ulcer.
t.  treated with  He also has been suffering from hypertension which has been treated
with Atenolol 50 mg daily.
u.  underlying  I would appreciate your assessment of this girl to find out whether he
has any underlying psychological problems.

 under control  Currently, her pain is under control with medication and she is
tolerating fluids.

 uneventful  Her second pregnancy and delivery were uneventful.

 urgent  I would appreciate if you could give urgent attention to Mrs. Woods'
problem.

 unremarkable  Cardiovascular examination was unremarkable and her

electrocardiogram was normal.

 to undergo  She underwent colonoscopy three years ago which was normal.
(simple past)

 treatment/surg  During hospitalization, the patient has undergone an electromyogram

ery/an and X-ray. (present perfect)
operation

v.  vital signs  Her vital signs were normal, but she was overweight (85 kg).
Therefore she was advised to reduce weight and do exercise.
w.  with a  Mr Gates presented at my clinic yesterday at 7pm with a complaint of
complaint of lower back pain.
Verb + preposition
Verb + preposition–certain verbs collocate with certain prepositions. When you learn a verb, take
note of any prepositions that follow and learn them together
e.g. The patient insisted on getting out of bed.

ANSWER
1.The patient would not consent to the procedure because her religious beliefs forbade it.
2.We will just have to wait for the results.
3.She should recover from the illness without further intervention.
4.We will have to substitute a different antibiotic for the penicillin.
5.We must prevent him from tearing out his IV line.
6.When the patient is discharged, be sure to provide him with the appropriate information sheets.
7.Many GPs believe in the value of counseling for distressed patients.
8.Many patients rely on information gleaned from the internet; however, too often it is inaccurate or
erroneous.
Adjective + preposition
take care to learn and use the correct prepositions that follow certain adjectives
e.g. This child is afraid of the dark. Be careful with that specimen!

ANSWER
1.This needle is not suitable for taking blood 1. from young children.
2.The symptoms were not related to her previous condition.
3.The patient will not be capable of any heavy lifting in the future.
4.I am pleased with the patient’s progress so far –it’s better than expected.
5.A copy of the patient’s medical history is attached to this letter.
6.The patient was not accustomed to hospital routine –it was her first admission.
7.She is serious about losing weight and getting fit to improve her quality of life.
8.The phlebotomist is responsible for the collection of appropriate volumes of blood in the
appropriate tubes.
Appropriateness of language
Formal vocabulary (formal vs spoken & casual English)
The written language of English is different to the spoken language in that it is quite formal
whereas the spoken form is more casual. If spoken language expressions are used in formal letters
it affects the “tone and register” of the letter. Therefore, it is important to maintain a formal tone
and use standard expressions.

Examples of language which should be avoided entirely include:

- Contractions (e.g. can’t, won’t, you’ll)
- Informal or colloquial language (e.g. tummy bug, meds, woozy).
- Personal pronouns (I think, I want her to...)
- Starting a sentence with and, but, also
o Also, the patient has a headache.
o The patient also has a headache.
o In addition, the patient has a headache.
-The use of personal opinion or inappropriate comments
o Unfortunately, Jonathan lives with his 22 year old single mother.
- Quoted speech (as opposed to reported speech)
o “He has often been inattentive in class,” the teacher said.
o The teacher reported that he had often been inattentive in class.

Examples of language which should be limited in favour of more formal language instead:
- Phrasal verbs (for example “fix up” “go to” “look into”)
o Please look into his home environment
o Please assess his home environment
- Writing too much in the first person
o I am writing to refer Johnathan Franks, a 6 year old patient.
o Johnathan Franks is a 6 year old patient.
- Overuse of active voice (as opposed to passive voice)
o I assessed Johnathan’s ears
o Johnathan’s ears were assessed.
- Too many simple sentences (as opposed to compound or complex sentences)
o Johnathan’s assessment shows difficulties learning. He struggles to hear the teacher.
o Johnathan’s assessment shows difficulties learning and he struggles to hear the teacher.
- The use of spoken language such as the word “get”
o Johnathan often gets tired in class.
o Johnathan often becomes tired in class.
Examples of Words which should be avoided entirely include:

Casual Formal

tell inform
start commence
Asks for requests
Think believe
get become
so very
but however
kids children
say state
get receive
got became
about regarding
really greatly
sad depressed
said stated
got received
So Therefore
a bit slightly
kid child
till until
like include
like such as
don't do not
Thanks Thankyou
Kids children
lots a lot of
Informal Formal

1. It is suspected that she may be suffering

1. I think she got a concussion when she banged her
concussion as a result of the blow to her head.
head.

2.Maggie was experiencing extreme nausea and vomited upon

2. Maggie was feeling really queasy and threw up
admission; staff initially suspected gastroenteritis.
when she came in so at first we thought she might
have a tummy bug of some sort.

3. The child is underweight for his age.

3. The child is too thin for someone his age.

4. He looked tired and in need of more food.

4. The elderly gentleman appeared thin and fatigued.

5. I’m sending this patient to you so you can

check what’s wrong with her
5. I am referring this woman to you for diagnosis
 Common error
Inappropriate Casual or Spoken Expression
1. Thanks for seeing Mr Eddy.
Thanks for arranging a home visit for this
patient. If you have any further questions,
please feel free to ask me.
“Thanks” is a casual and should be written in full.
2. I would really appreciate your attention regarding
further management of this patient.
“Really” is spoken language and should be avoided .
3. About his dietary habits, he eats a lot of oily and sweet 3.Regarding his dietary habits, he eats a large
food.
She had lot of pain.
About is a casual expression, regarding is more suitable.
“A lot of” is also casual.“A large amount of”is more formal.
4. Social history revealed nothing significant.
Nothing is more commonly a spoken expression which is
not suitable for writing.
5. Please do not hesitate to contact me, if u need
additional information.
Definitely no text or SMS language in formal letters.
Replace with: you
6. She has got maternal postpartum haemorrhage of
800mls.
7. Mr O’ Riley got an appointment for a follow up visit
with his general practitioner, Dr. Avril Jensen.
The mother got sick for a few days.
Got/Get are casual expressions and should generally be
avoided in formal letters.
8. Should you have any concerns regarding to them,
please do not hesitate to contact me.
The pronoun them sounds casual here. It is much better to
use the patient’s name, especially in the final sentence of
the letter.
9. At the moment, she is weak and disorientated
sometimes but severe pain has been alleviated.
Sometimes is a casual expression. More formal expressions
include: at times or on occasions
Appropriate Formal Expression
1.Thank you for seeing Mr Eddy.
Thank you for arranging a home visit for this
patient. If you have any further questions,
please be free to ask me.
2.I would very much appreciate your attention
regarding further management of this patient.
I
would greatly appreciate your attention
regarding further management of this
patient.
amount of oily and sweet food.
She had a lots of pain.
4.Social history revealed no significant findings.
5.Please do not hesitate to contact me, if you
need additional information.
6.She has had maternal postpartum
haemorrhage of 800mls.
7.Mr O’ Riley has an appointment for a follow
up visit with his general practitioner, Dr.
Avril Jensen.
The mother became sick for a few days
8.Should you have any concerns regarding
Nicole and her baby, please do not
hesitate to contact me.
9.At the moment, she is weak and
disorientated at times/on occasions but
severe pain has been alleviated.
10. This pain was exaggerated to cold and hot things
Things is a casual expression and should be avoided
11. A repeat vaginal examination revealed a very
tender right vaginal fornix. But her blood
pressure pulse is within normal range.
It is not good to begin a sentence with the
conjunction but In this case use However, it is more
formal
12. Abdominal examination revealed a small right
groin swelling that’s consistent with inguinal
hernia.
It is best to avoid contractions in formal letters as
these are used more in spoken English, texting &
informal letters.
13. Thank you for your expert care and please don't
hesitate to contact us if you require further
information.
It is best to not use contractions such don’t, can’t etc
Always write out such words in full.
14. She was given her general advise for
softening her stool,like changing her dietary
habit but she was non compliant.
Like is a casual expression. it is recommended
to use such as or including
15.She refuses to eat solids and prefers fluids only
like apple juice and lemonade.
16.In view of the above signs and symptoms I
think she is suffering from schizophrenia.
The patient's family is thinking about a
reduction in her medication.
think is informal and preferable expression is either
believe or consider, depending on the context
17.Her temperature and blood pressure were
normal while pulse was elevated at 88. So I
recommended that she return today for a blood
test and reassessment.
10.This pain was exaggerated to hot and cold
stimuli.
11.A repeat vaginal examination revealed a very
tender right vaginal fornix. However, her blood
pressure pulse is within normal range.
12.Abdominal examination revealed a small right
groin swelling that is consistent with inguinal
hernia.
13.Thank you for your expert care and please do
not hesitate to contact us if you require
further information.
14. She was given her general advise for
softening her stool, such as changing her
dietary habit but she was non compliant.
She was given her general advise for softening
her stool, including changing her dietary habit
but she was non compliant.
15. She refuses to eat solids and prefers fluids
such as apple juice and lemonade.
16. In view of the above signs and symptoms I
believe she is suffering from schizophrenia.
The patient's family is considering a reduction
in her medication.
17.Her temperature and blood pressure were
normal while pulse was elevated at 88.
Therefore, I recommended that she return
today for a blood test and reassessment.
18.There was evidence of poor oral hygiene, 19.There was evidence of poor oral hygiene
carious lesions and active periodontal disease too. ,carious lesions and active periodontal disease
too is informal, a more formal expression is as well . as well.

19.She had had termination of pregnancy 10 19. She had had termination of pregnancy 10
years back. years ago.

20.He had a habit of thumb sucking till the age of5 20.He had a habit of thumb sucking until the
Till is casual, until is formal age of 5

21.She was so anxious. 21.She was very anxious..

So is informal and subjective, where as very is more
formal and objective.

22.Owen has big tonsils. 22.Owen has enlarged tonsils

big is informal and does not sound professional.

23.I am writing to request a follow-up for this 23.I am writing to request a follow-up visit for
patient. this patient.

24.Examination revealed that his vitals were stable 24.Examination revealed that his vital signs
and left knee was swollen without effusion. were stable and left knee was swollen without
effusion.

25.Examination revealed normal vitals. 25.Examination revealed that his vital signs
were normal.
Vitals and follow up are incomplete expressions,
commonly used in spoken English, but not suitable for
formal writing.

26.I recommend some investigations to rule out 26.I recommend further investigations to rule
cancer. out cancer.

27.I requested some blood tests. 27.I requested additional blood tests
Some is vague and does not sound professional.
28.In addition, she is just able to tolerate fluids. 28.In addition, she is only able to tolerate fluids.
Just can sound informal at times.
29.Her BMI was 28 and all the rest of the 29.Her BMI was 28 and the remainder of the
examinations were normal. examinations were normal.
all the rest of sounds informal.

30. She There are several measures which can be 30.There are several measures which can be
taken to reduce the risk of infection like taking a taken to reduce the risk of infection including
shower in morning, using separate towel for taking a shower in morning, using separate
everyone, changing underwear and bed sheets towel for everyone, changing underwear and
regularly, vacuuming carpets, keeping the nails bed sheets regularly, vacuuming carpets,
short and washing hand thoroughly. keeping the nails short and washing hand
thoroughly.

31. Her temperature and blood pressure were 31.Her temperature and blood pressure were
normal while pulse was elevated at 88. So I normal while pulse was elevated at 88.
recommended that she return today for a blood Therefore, I recommended that she return
test and reassessment. today for a blood test and reassessment.

So is a casual word, you can use it within a sentence,

but not to start a sentence in formal writing. Replace
with: Therefore,

32. Her husband was upset because, she was not

32. Her husband was upset because, she was
showing interest towards the kids.
not showing interest towards the children.
 Mark's dad also suffers from this condition.
• Mark's father also suffers from this condition.
 The teacher spoke to her mum regarding the
• The teacher spoke to her mother regarding
regular absences from school.
the regular absences from school.
kids, dad, mum are all spoken expressions which are
inappropriate in formal letters.

33.Mrs. Jones is a widow who complained of 33.Mrs. Jones is a widow who complained of
persistent chest pain at roughly 1.45pm. persistent chest pain at approximately 1.45pm.

34.Miss Roberts started smoking around 6 months 34.Miss Roberts started smoking approximately
ago. months ago.
35.I think she got a concussion when she banged 35. It is suspected that she may be suffering
her head. concussion as a result of the blow to her head.

36.Maggie was feeling really queasy and threw 36.Maggie was experiencing extreme nausea and
up when she came in so at first we thought vomited upon admission; staff initially
she might have a tummy bug of some sort. suspected gastroenteritis.

37.The child is too thin for someone his age. 37.The child is underweight for his age.

38.He looked tired and in need of more food. 38.The elderly gentleman appeared thin and
fatigued.

39.I’m sending this patient to you so you can 39.I am referring this woman to you for
check what’s wrong with her diagnosis..
Medical Jargon and Medical terminology

Medical Jargon
 The vocabulary and expression must be of a suitable standard

Medical terminology - abbreviations & Acronyms

Abbreviations - shortened forms of a word/phrase e.g.10 mg

acronyms–the initial letters or syllables of a name/phrase used to make a new word e.g.AIDS
initialisms – a series of letters read separately e.g.MRI
 Do not overuse medical terminology including abbreviations and acronyms
 the abbreviations and acronyms been written in full

Medical Jargon

Common Errors
Incorrect Correct

1. Her current medications include sid Metformin 1. Her current medications include a daily
500 mg. mane and nocte, Glycosamine dose of Metformin 500 mg. in the morning
5mg.mane and Candesartan 10mg. nocte. and at night, Glycosamine 5mg.in the
morning and Candesartan 10mg. at night.
2. After discharge from hospital, Mrs.Jones has been 2. After discharge from hospital, Mrs.Jones
told to take Aperients (PRN) and Aldomet (250 mg has been told to take Aperients when
bid). required and Aldomet twice a day.

3. I treated Claudia with prednisolone 5mg 1t/sid for 3. I treated Claudia with prednisolone 5mg
seven days. tablet once a day for seven days.
 Medical Terminology - Abbreviations & Acronyms

The medical case notes for the OET exam often contain abbreviated language.
The task for the writer is to expand these into full words and sentences.

Exceptions to this rule include abbreviations of measurement. Therefore it is

acceptable to use the following:
 cm for centimetre
 kg for kilogram
 ml for millilitre
 mg for milligram
 mm hg for millimetre of mercury

There are 3 reasons why medical acronyms should not be used.

1. As the OET is a test of English, you need to demonstrate your ability to transfer
technical language in the case notes into standard English.

2. For some letters you are may have to write to someone who is not a health
professional such as a social worker or family member.

3. A referral letter is not a report so the standard conventions of letter writing

require a formal style which includes using complete words and sentences.
Handy Hint: It is a test of English not Latin, so where possible avoid the use of Latin
based acronyms and words.
Here is a list of common abbreviations used in Australia.
Acronym/Short Form Full Expression
hx history
PMH past medical history
C/O complains of
DOB Date of Birth
R right
L left
Abdo Abdomen
BP blood pressure
P/PR Pulse/Pulse Rate
ADL activities of daily living
NAD no abnormality detected
? rheumatic fever possibility of something
y/yrs year
3/12 3 months
h hour
Tab tablet
Cap capsule
IV intravenous
nocte in the evening
mane in the morning
AC before meals
sid once a day
BD/bid 2 times a day
TDS/tid 3 times a day
QID 4 times a day
6/h 6 hourly
PRN as required
OPG orthopantomogram
BW x-rays bite wing x-rays
ECG electrocardiograph
FTA failed to Attend
w/o without
Lab laboratory
FBC full Blood Count
+ positive
 Common Errors
Incorrect
On examination, there was tenderness and rebound
tenderness over the R. iliac fossa.
Left and right must be written in full and not simply
copied from the case notes.
I am writing to refer Mrs. Wilson, a 45yr old
woman who is suffering from signs and symptoms
suggestive of advanced English
She presented to me yesterday evening with
abdominal pain mostly in the left iliac fossa which had
been present for the last 24 hrs.
hr is an abbreviation and should be written in full
Her mother died of MI
On examination she was found to have PR 88/min
It is important to expand on the abbreviations used in
the case notes.
Mr Duane Eddy 57/m is an a urgent referral
regarding an ulcer in R. lateral border of tongue.
It is important to expand on the abbreviations used in
the case notes.
I would appreciate if you could inform me about her
treatment & progress over the next few days.
The patient was discharged on Dec. 30 2009.
Lab work and review was planned for the next
morning
Re: Vamuya Obeki, 4 yr old child
30 Dec. 08
BP
P pulse
ECG
OPG
GP
Correct
On examination, there was tenderness and
rebound tenderness over the right iliac fossa
I am writing to refer Mrs. Wilson, a 45-year
old woman who is suffering from signs and
symptoms suggestive of advanced English.
She presented to me yesterday evening
with abdominal pain mostly in the left iliac
fossa which had been present for the last
24 hours.
Her mother died of myocardial infarction
On examination she was found to have a
pulse rate of 88 beats per minute.
Mr Duane Eddy, a 57 year old male is an a
urgent referral regarding an ulcer in the
right lateral border of tongue
I would appreciate if you could inform me
about her treatment and progress over the
next few days.
The patient was discharged on December
30 2009.
The patient was discharged on 30/12/09.
Laboratory work and review was planned
for the next morning.
Re: Vamuya Obeki, 4 year old child
30 December 2008
blood pressure
Electrocardiogram
Orthopantomogram
General Practitioner
Common Mistakes Regarding Physical Description
Incorrect
Advice was given to reduce her weight.
After the verb reduce it is not necessary to follow
with a pronoun. So you is not required. Simply
say:
I advised him to reduce weight, or, you need to
reduce weight.
In addition, she had lost her weight.
After the verb lose it is not correct to follow with
a pronoun.
He is now obese with a 99 kilos weight and a 170
cm height.
The use of the correct verb & noun form and
associated grammar is difficult. Refer opposite for
correct usage.
Today’s examination revealed multiple missing
teeth, various carious lesions and a periodontal
pocket of depth 4-9mm.
There are several periodental pockets with about
4-9 mm in depth.
Correct word order is:
 Depth of 4-9mm
 Height of 173cm
 Length of 20 m
 Weight of 78kg
His height was 173cm. Weight can change but
height can not so don’t use past tense.
He was overweight 85 Kg with respect to his
height 173 cm.
This sentence is a shortened version similar to the
case notes. It is important to write in full
sentences.
Correct
Advice was given to reduce weight.
The patient was advised to reduce weight.
A reduction of weight was advised.
In addition, she had lost weight.
In addition, she has lost a further 11 kg of weight
over the past 2 months.
In addition, the patient’s weight has significantly
reduced from 61 kg to 50 kg over the past 2
months.
He is now obese with a weight of 99 kg and a height of
170cm. (noun form)
He weighs 99 kg and is 170cm tall. (verb form)
He weighs 99kg and is 170cm in height. (verb form)
Today’s examination revealed multiple missing
teeth, various carious lesions and a periodontal
pocket depth of 4-9mm.
There are several periodontal pockets which are
about 4’9 mm in depth or
There are several periodontal pockets with a depth
of about 4-9 mm.
His height is 173cm.
He was overweight at 85 kg with respect to his
height of 173 cm.
Common Errors with Difficult Words
Prescribe ,suggest and recommend
Prescribe , Suggest and recommend are all words commonly used in referral letters to report
information were given to the patient. However their rules of use differ and result in errors. Here
are some examples of their correct and incorrect usage.
Incorrect Correct

1. I have prescribed him Amoxil 500mg. 1. I have prescribed Amoxil 500mg.

I have prescribed Panadol to ease the pain.
Panadol was prescribed to ease the pain.
(Passive)
2. I recommend him to rest for 3 days 2. I recommend that he rest for 3 days

3. I have suggested him to see you next week. 3. I suggested (that) he see you next week.
I
advised him to see you next week

4. I suggested her to return in morning as she 4. I suggested (that) she return in morning as
required further blood test and she required further blood test and
assessment. assessment.
I advised her to return in morning as she
Explanation: required further blood test and assessment.
The words suggest & recommend cannot be
followed by an object pronoun such as him/her
whereas advise can.
The word prescribed should not be followed with
an object pronoun such as him/her/them/you. It
is best to follow directly with the medication
name.
Advise or Advice
Advise is a verb while advice is a noun. The noun advice is uncountable so it can not be used in
plural form, i.e. advices. So you can make sentences in two ways:
1. to advise his parents…..
2. to provide advice regarding medication.
Incorrect Correct
 It would be greatly appreciated if you  It would be greatly appreciated if you
could make a visit to this family and could make a visit to this family and
advice his parents regarding the advise his parents regarding the
recommended vaccines for both recommended vaccines for both children.
children.  I am writing to refer this patient to you
 I am writing to refer this patient to you for for advice regarding the management of
an advice regarding the management of his his bilateral inguinal hernia.
bilateral inguinal hernia.
Complain or Complaint

Complain is a verb whereas complaint is a countable noun

Incorrect
1. the patient complaints of chest pain and
her blood pressure was high
2. The patient presented with a complain of
chest pain.
3. The patient presented with complaint of
chest pain.
4. He presented to my office on 23/03/2008
complaining on severe pain associated
with the lower left first molar.
Affect or Effect
Correct
1. the patient complains of chest pain and her
blood pressure was high
2. The patient presented with a complaint of
chest pain.(noun)
3. The patient presented with a complaint of
chest pain.(article required)
4. He presented to my office on 23/03/2008
complaining of severe pain associated with
the lower left first molar.

Affect is a verb while Effect is a noun. So you can make sentences in two ways:
1. The patient has been affect by the treatment.
2. The effect of the treatment is unknown.

Incorrect Correct
 She is also been effected by glaucoma for  She is also been affected by glaucoma for the
the past 4years. past 4years. (verb)

 The side affects of this medication are  The side effects of this medication are
unknown. unknown. (noun)

Widow or Widower
 Widow (noun)refers to a woman whose husband has died and who has not remarried
 Widower (noun)refers to a man whose wife has died and who has not remarried
 Widowed (adjective) refers either a man or woman whose spouse has died and has not remarried.
Incorrect Correct
 I am writing to refer, Ms Greerson, a 58-  I am writing to refer, Ms Greerson, a 58-year-
year-old, widowed, admitted with pain, old widow, who was admitted with pain,
dehydration and nausea. dehydration and nausea.
 I am writing to refer this patient a 58-year-
oldwidowed woman who admitted with pain,
dehydration and nausea.(adjective)
 I am writing to refer Mr. Saunders, a 60-  I am writing to refer Mr. Saunders, a 60-year-
year-old widow who complained of pain in old widower who complained of pain in his
his upper right second molar. upper right second molar.(noun)
 Confident or Confidence

Confident is an adjective whereas confidence is a noun

Incorrect Correct
 …but the patient has not confident in  The patient has no confidence in feeding
feeding, bathing and caring for baby (noun form)

 The patient is not confidence in social  The patient is not confident in social
situations. situations. (adjective form)

Personal or Personnel

Personal is an adjective, whereas personnel is a noun.

Incorrect Correct

 It would be greatly appreciated if your  It would be greatly appreciated if your

specialized personal can take care of her. specialized personnel can take care
 Allergy Vs Allergic

Allergy is a countable noun whereas Allergic is an adjective

Incorrect
 In addition, he is known allergic to nuts for
which he was
 admitted to hospital with anaphylaxis 2 years
ago.
 Regarding his medical history he is allergy to
Sulphur containing drugs.
Correct
 In addition, he has a known allergy to nuts for
which he was admitted to hospital with
anaphylaxis 2 years ago.(noun)
 In addition, he is known to be allergic to nuts
for which he had been admitted in the hospital
with anaphylaxis 2 years ago.(adjective)
 Regarding his medical history he has an allergy
tosulphur containing drugs.(noun)
 Regarding his medical history he is allergic to
Sulphur containing drugs.(adjective)

a few/few & a little/little

Few and a few is used with plural nouns, and little and a little is used with uncountable nouns.
Little and few Have negative connotations and are similar in many to not much/ not many.
A little and a few have positive Connotations and are similar in meaning to some.
Mixing up these words therefore will completely change the meaning of the sentence.

Incorrect Correct
 The patient has reduced speech output and a  The patient has reduced speech output and
little eye contact. little eye contact.(negative connotation
required here)

 There are few ways to help identify the possibility  There are a few ways to help identify the
of threadworms such as checking the anus of your possibility of threadworms such as checking
children at night and frequent scratching. the anus of your children at night and frequent
scratching.(positive connotation required)
During /while

During is followed by a noun

hospital.

While is followed by a phrase or gerund: ____ing

Incorrect Correct
 He twisted his ankle during playing squash 3  He twisted his ankle during a game of
months ago. squash 3 months ago.
 He twisted his ankle while playing squash 3
months ago.
Following / followed by

Incorrect Correct
 She was admitted to our hospital followed by  She was admitted to our hospital following a
a collapse at home with dehydration,nausea collapse at home with dehydration, nausea
and severe pain. and severe pain.

Incorrect as it means the patient was admitted to Correct as it means the collapse occurred
hospital first, then collapsed before being admitted to hospital.

History
History is always present, never past because you can’t erase it! Therefore you need to use simple
present tense not past tense when using this expression.

Incorrect Correct
 Mrs. McGowan had a history of heart  Mrs. McGowan has a history of heart
palpitation of 3 day duration.. palpitation of 3 day duration.
Request
Request can be both a verb and noun.
Request as a verb
Request as a noun
Incorrect
 The patient requested for new dentures.
 Ms. Green requested about IVF treatment.
Explanation: The common mistake is to use the
verb form plus preposition which incorrect.
Explain Vs Tell
Explain and tell also have different rules which cause confusion
Incorrect
 I explained them that unsuccessful conception
was not unusual in their case.
 I have already explained the couple the basic
advice regarding conception.
Explanation: The word explain cannot be followed
by a pronoun or noun without the preposition to
whereas tell can.
request+for)
Correct
 The patient requested new dentures. (verb)
 The patient made a request for new
dentures. (noun)
 Ms. Green requested IVF treatment.(verb)
 Ms.Green made a request for IVF
treatment. (noun)
Correct
 I explained to them that unsuccessful
conception was not unusual in their case.
 I told them that unsuccessful conception
was not unusual in their case.
 I have already explained to the couple basic
advice regarding conception.
 I have already told the couple basic advice
regarding conception.
 Common Errors - Years Vs Year
Incorrect Correct
I am writing to refer this patient,63 years old man 1. I am writing to refer this patient, a 63-
who lives alone. year- old man, who lives alone.
In this sentence there are two mistakes:
1. the expression is a phrase and therefore 2. There are two 63-year-old men in the
requires an article “a “ to precede the phrase waiting room.
a 63-year-old man. An article is required
because the noun man is singular.
Compare with: There are two 63-year-old
men in the waiting room.
2. Years is an adjective in this sentence (it
describes the age of the man) and adjectives
are uncountable.
This patient is 63 year old. This patient is 63 years old.
In this sentence the word years is a noun preceding
an adjective old. Nouns can be countable so in this
case you must make it plural.
Her father died at 50 year old of bowel cancer 1. Her father died at 50 years of age of
In this case at is a preposition and needs to be bowel cancer
followed by a noun or noun phrase, rather than the 2. Her father died at the age of 50 of bowel
adjective” old”. See column on the right for possible cancer
correct choices. Year is a noun in this case so it 3. Her father died when he was 50 years old
should be written in plural form. of bowel cancer.
Other examples
1. In addition, he had a habit of thumb sucking 1. In addition, he had a habit of thumb
until age of five years. sucking until the age of five.

2. In addition he had a habit of thumb sucking 2. In addition, he had a habit of thumb

until he was five years age. sucking until he was five years of age.

3. Regarding the medical history, Alfie has a 3. In addition, he had a habit of thumb
history of thumb sucking until the age of 5 sucking until he was five years old.
years,
1. In addition she has fillings, crowns, good 1. In addition she has fillings, crowns, good
dental hygiene and a 13 years old chrome dental hygiene and a 13 year old chrome
/cobalt removable partial denture. /cobalt removable partial denture.
Years is an adjective in this sentence (it describes
the age of the denture) and adjectives are
uncountable.
The criteria used to assess your writing in the OET exam including

1: Overall task fulfilment

1A: Have you selected case notes that are relevant to the reader?
For every OET writing task you do, your content, structure, language and tone may need to be
changed to meet the needs of who you’re writing to. This is related to the following
comprehension questions:
• What is your role?
• Who is the intended reader?
• What is the current situation?
• What is the main point you must communicate to the reader?
• What supporting information needs to be given to the reader?
• What background information is useful to the reader?
• What information is unnecessary for the reader? - Why is it unnecessary?

Please note that you are not going to lose marks simply because you are not within the required word
count. More important than the number of words is how those words are used. There is no hard and
fast rule that the word count for a writing task must be within 180-200 words; this is only a guide as
to approximately how many words should be written. The OET writing task is designed in such a way
that if you choose the information which is relevant to the reader, you will naturally write close to the
180-200 word range. If you happen to choose everything that is relevant but fall outside of this range
then this is not a problem. The word count should be seen as a symptom of whether the amount of
content they have written is relevant.

1B: Have you transformed the notes into your own words? Paraphrasing
is important as you need to demonstrate an ability to write the notes into your own words.

1C: Is the task catered to the needs of the reader?

This is related to the following comprehension questions:
• What is your role?
• Who is the intended reader?
• What is the current situation?
• What is the main point you must communicate to the reader?
• What supporting information needs to be given to the reader?
• What background information is useful to the reader?
• What information is unnecessary for the reader? - Why is it unnecessary?
2: Appropriateness of language

2A: Is the most important information prioritised?

• The ordering of the information
• How the very important points (such as the hysterectomies) are emphasised and expanded on
• How the slightly important information is briefly paraphrased

2B: Is the letter organised clearly? A format which will fit most scenarios is as follows:

• Introduction: Including purpose of writing and chief complaint in brief

• Body Paragraph 1: Patient social history
• Body Paragraph 2: Patient medical history
• Body Paragraph 3: Discharge plan or your main concern in detail
• Conclusion: Concluding request specific to the task
set out the name, date and address given at start of letter clearly
explain the current situation at start of letter.
as you write, indicate each new paragraph clearly by leaving blank line.
Note: Body paragraphs 2 & 3 can be interchanged depending on the task.

2C: Is the main purpose stated at the start of the letter?

If we look at the introduction , we can see the main purpose is clearly stated
Please note that in some cases there could be sections of the treatment plan which are not relevant
to the reader at all. In the case of this letter, the weight loss management and pelvic floor exercises
are not relevant to the purpose of the letter at all because these are your responsibility, not the
reader’s.
2D: Is an appropriately formal tone used?

A referral letter is considered a formal letter and therefore requires appropriate language to be used.
Thus more informal phrases, words and expressions should be avoided or limited in an OET letter.
Examples of language which should be avoided entirely include:
- Starting a sentence with and, but, also
o Also, the patient has a headache.
o The patient also has a headache.
o In addition, the patient has a headache.
-The use of personal opinion or inappropriate comments
o Unfortunately, Jonathan lives with his 22 year old single mother.
- Quoted speech (as opposed to reported speech)
o “He has often been inattentive in class,” the teacher said.
o The teacher reported that he had often been inattentive in class.
Examples of language which should be limited in favour of more formal language instead:
- Phrasal verbs (for example “fix up” “go to” “look into”)
o Please look into his home environment
o Please assess his home environment
- Writing too much in the first person
o I am writing to refer Johnathan Franks, a 6 year old patient.
o Johnathan Franks is a 6 year old patient.
- Overuse of active voice (as opposed to passive voice)
o I assessed Johnathan’s ears
o Johnathan’s ears were assessed.
- Too many simple sentences (as opposed to compound or complex sentences)
o Johnathan’s assessment shows difficulties learning. He struggles to hear the teacher.
o Johnathan’s assessment shows difficulties learning and he struggles to hear the teacher.
- The use of spoken language such as the word “get”
o Johnathan often gets tired in class.
o Johnathan often becomes tired in class.
2E: Are salutations and titles used correctly?

a general rule “Dear” followed by the reader’s title then last name is the most suitable opening. If the
reader’s name is unknown, “Dear Sir/Madam” is suitable. Whether the greeting ends in a comma,
colon or nothing at all is a stylistic choice and not considered important by OET examiners. For
closings, “Yours sincerely” followed by the writer’s name and/or job is the most common. Once
again, punctuation following the closing is a stylistic choice. Using “Yours faithfully” is also acceptable
if you don’t know the reader’s name.
we can see the writer has incorrectly used “Dr McCauley.” When a surname is hyphenated, we
should include the whole name, complete with the “-“, when we write their surname.

2F: Are abbreviations and medical terms used appropriately?

Abbreviations can be used in OET writing providing that:

- Their use isn’t overdone to such a degree that the letter is hard to read.
- The intended reader would be able to understand it.
- They aren’t used as a shortcut grammatically. For example, “Her BP 126/75, P 72
3: Comprehension of stimulus

3A: Has the main purpose of the task been understood?

This doesn’t just mean the individual notes and the patient details, they also want you to
demonstrate you understand who you’re writing to and why you are writing to them. The best way
to demonstrate this is by selecting relevant notes to put in your letter and changing the wording and
order of the notes to suit the needs of the reader.
It’s strongly recommended that you read the end of the task first (i.e. the “treatment plan,”
“management,” or “writing task” sections) so you know who you are writing to and why before you
read the medical notes. This will help you know what is and is not relevant while you read the notes
for the first time.

3B: Are the most relevant issues clearly stated to the reader?

When choosing which notes to include in your letter, please keep in mind that you aren’t just
choosing what is and is not important. You also need to consider how important they are. If anything
is particularly important, it needs to be made clear to the reader. The best way to do this is by
mentioning it in the introductory paragraph. Repeating important issues later on in the letter is
another effective way of making something relevant clear to the reader.

3C: Have all case notes been properly understood?

If your feedback provider has suggested you wrote something which lacks understanding you should
ask yourself why you wrote this. There are two particularly likely reasons.
The first reason is misunderstanding vocabulary. For example “The patient was admitted to the
physiotherapist for not following the pelvic floor exercises”, rather than “The patient admitted to not
following the pelvic floor exercises”. In this example the writer has miscomprehended what
“admitted” means. If this is your problem, you should study the vocabulary you didn’t understand.
Reading more medical notes, particularly from practise OET writing exams, can help.
The second reason is misunderstanding who you’re writing to. For example, someone writing “The
patient needs to see a gynaecologist” rather than “The patient needs to see you”. In this case the
writer hasn’t realised that he/she is actually writing to the gynaecologist
4: Control of linguistic features (grammar and cohesion)

4A: Is grammar used to make points clearly?

When it comes to grammar, using it appropriately is just as important as avoiding errors. What you
want to do is choose grammar which will express meaning as clearly and effectively as possible. If
you want to improve in this area, what you should do is ask yourself what a particular type of
grammar means, when it should be used, and how it differs from other types of grammar.
For example, if you were to look at the present perfect tense, you could ask yourself:
- What does present perfect tense mean?
- When should present perfect be used?
- How does present perfect differ from past simple or past perfect?

Other examples of using grammar to make a point clearly include:

- Passive tense indicate who or what something is done to is more relevant than who or what does
it (e.g. I checked the patient’s blood pressure. The patient’s blood pressure was checked).
- A mix of present perfect and past simple tenses used to distinguish between what happened in
the recent past and the not so recent past.
- The correct use of parallel structures when linking different items in one sentence (parallelism).
- Nominalisation used to place the most important information into noun phrases.
- Subordination used to show how one clause is of more relevance than another.

4B: Is a wide range of grammatical knowledge appropriately displayed?

As well as looking at how many grammatical mistakes are made, assessors will look at what range of
grammar was attempted. If there is a part of the letter where a particular form of grammar would
have been more appropriate but was avoided, the assessor may assume this was because the writer
didn’t know how to produce it.
4C: Is a mix of long and short sentences used? Transform case notes into complete sentences
In OET writing, a range of sentence lengths should be used. Please note that there is no correct
number of long and short sentences which should be used in your writing. As a general rule, we want
a variety of the following sentence types:

- Simple sentences –are sentences which contain just one clause (phrase+ a subject + a verb) :
o The patient was tired.
o Mr Smith had not been sleeping well.
o He had been prescribed sleeping tablets.

- Compound sentences – These are sentences which contain 2 or more clauses linked together
using a coordinating conjunction (and, but, so, or, for, nor, yet). For example, we can link the
first two simple sentences above with a coordinating conjunction to make a compound sentence:
o Mr Smith had not been sleeping well so he was tired.

- Complex sentences – These are sentences which contain 2 or more clauses linked together using
a subordinating conjunction (although, as, because, if, since, when, where, while, several more).
 Clauses of Contras , Clauses of Purpose , Clauses of Reason , Clauses of Time
Unlike compound sentences, a complex sentence can have the conjunction at the start
or middle of a sentence and will require a comma sometimes.
In addition, the two clauses are not seen to be equally as important as each other.
This means that a complex sentence can be very effective when used well but should only be
used in the right situation. If we take the two simple sentences above, we can link them in the
following ways:
o As Mr Smith had not been sleeping well, he was tired.
o Mr Smith was tired as he had not been sleeping well.

- Compound-complex sentences – These are sentences which contain both coordinating and
subordinating conjunctions. This means they will contain at least 3 clauses. We can try linking
all three of the simple sentences to make a compound-complex sentence:
o Although Mr Smith had been prescribed sleeping tablets, he had not been sleeping well
so was tired.
4D: Are grammatical errors which affect comprehension avoided?

Grammar mistake – This is when you write something incorrectly which you’d often be able to write correctly
if you had been more careful. For example, if you are usually good at when to use “have” or “has” but for
some reason you accidently wrote “The patient have 5 children” then this would be a grammar mistake.
If you are making grammar mistakes, this can often be due to not proofreading your work properly or not
having enough time to proofread. If you aren’t proofreading properly, you should practise checking through
your writing before asking someone else to check it for you. If your issue is not having enough time to
proofread perhaps you are writing and planning inefficiently or you’re writing too many words.
Grammar error – This is when you write something incorrectly because you don’t know how to write it
correctly. For example, if you don’t understand the difference between “have” and “has” then writing “The
patient have 5 children” would be a grammar error. To fix a grammar error, you need to study and practise
this particular area of grammar.

4E: Verb usage - Tense verbs

If you have a problem with verb tenses, the first thing you need to do is work out which tenses exactly
you are having problems with. Please note that avoiding the use of a particular tense would be
considered just as much of a problem as making errors or mistakes when using a particular tense.
Once you have identified the tenses you’re having trouble with, you need to study:

- What the tense means

- When the tense needs to be used
- The form of the tense
- How to proofread your own writing when using this tense.

4F: Articles : (definitive/ indefinite) Articles usage with Countable & Uncountable Nouns

Problems with articles can often be hard to overcome because they are quite ingrained into the way in
which we write. If you have problems in this area, first ask yourself if this is occuring due to a lack of
understanding about the rules for articles or if it’s due to having problems with breaking your old article
usage habits.
4G: Nouns (singular and plural)

Sometimes candidates have problems with determining if a noun is countable or uncountable. If you are
having this problem, try remembering particular patterns with nouns such as:
- Therapy is uncountable (physiotherapy, chemotherapy)
- Tests are countable (a blood test, an x-ray)
- Medication is uncountable (Panadol, beta blockers)
- Body parts are countable (legs, a heart)

Remembering these examples should help you with determining what is and is not countable.

4H: Word order & sentence structure

If you have problems with word order, you need to study language at a clause or phrase level while paying
attention to word types. You may also need to review particular types of clauses in which you are having
trouble.
If sentence structure is an area of weakness, first you need to consider what types of sentences you are
having problems with. Is it just simple sentences or is it complex/compound sentences? Is it embedded
clauses? You need to use a variety of different sentence types but you should take steps to master these
before using them.
Related to this is “parallelism”, which is maintaining consistent structure of words when linking different
phrases. For example, the sentence below is not parallel:
The patient was tired, disorientated and had a fever.
In this sentence the word types of the 3 symptoms are different (The patient was adjective, adjective and
verb noun). To be parallel they should all be adjectives or nouns, not a mix of the two. So we can choose
one of these instead:
o The patient was tired, disorientated and feverish.
o The patient was suffering from tiredness, disorientation and fever.

4I: Use of prepositions / Phrasal Verbs and Prepositions.

Candidates can often find prepositions difficult due to there not being many rules or patterns in their usage.
If you are having such problems, studying particular commonly used phrases found in OET writing can help
you improve.
4J: Passive voice

While passive voice can be hard at first, there are particular forms it can be used in which become easier to
use with practise. As well as learning the form, it’s very important that you become familiar with when it is
suitable to use passive rather than active voice. For example, when what was done (treatment) or who it
was done to (the patient) is more important than who (the doctor) or what (the hospital) did it
I checked the patient’s blood pressure. // The patient’s blood pressure was checked.
The hospital admitted the patient. // The patient was admitted.

4K: Subject/verb agreement

This is an area of grammar which is taught to lower level students but mistakes can still occur once a
student acquires an advanced level of English. If you make these mistakes, ask yourself if you are able to
understand the mistake once it has been pointed out to you. If you are, the problem is most likely due to
habit and can be resolved by proper proofreading. To improve in this area, always practice checking for
errors by yourself before receiving feedback from a teacher. You should also ensure you leave some spare
time towards the end of the writing test so you can proofread.

4L: Other grammatical issues to be learned/practised include:

- Use of Modals
- Reported speech
- Determiners & quantifiers
- Relative clauses
- Pronouns
- Adjectives
- Adverbs
- Adverbial clauses
4M: Are connecting words and phrases appropriately used to link ideas?

In this section we are looking at several issues related to connecting words including:
- Correct use of coordinating (and, but, or…) and subordinating (if, although, because…) conjunctions
- Correct and appropriate use of transition words (However, In addition, Therefore…)
Be sure to pay particular attention to the correct use of commas when these words are used.
Phrases should only really be linked with a connective device if there is a close enough connection between
those phrases to justify linking them. For example, this sentence is grammatically correct but there’s not
really any link between the two clauses:
He has had learning difficulties at school and he is underweight for his age.
While these cohesive devices can help your writing, you need to ensure you don’t overuse them as this can
make your writing repetitive.
The best way to achieve a high level of cohesion is by using a variety of different types of cohesion and to
only use them when there is a close enough relationship between statements to justify their usage.
5: Control of presentation features

5A: Is punctuation used correctly?

This includes all elements of punctuation. Please note that variations in punctuation, including the use of
an Oxford Comma, can be accepted as long as they are consistently applied.

5B: Are paragraphs clearly displayed?

OET recommends that candidates leave a single line space between each paragraph but it’s not essential.
Indenting the first line of a paragraph is acceptable if the candidate prefers to do this. What’s most
important is that the way paragraphs are displayed remains constant throughout the letter. So if a line
space is used in one case, it should be used in all others. If the first line of one paragraph is indented, all
others should be.

5C: Is spelling of an adequate level?

Ideally we’d like there to be no spelling mistakes at all but it’s likely there could be a few. Whether or not a
mark is lost for a spelling mistake could depend on how much it reduces comprehension and how common
the word is.

5D: Is appropriate letter format used?

A number of different letter formats are in accepted use by health professionals in different local contexts.
There is therefore no single particular format that you have to use in your response in the OET Writing
sub-test. It is important that your letter is clearly laid out and appropriate for the particular task, but there is
no set OET layout.
Typically, the name and address of the person to whom you’re writing, the date and the name of the
patient should be mentioned at the top of the letter. The letter should also close with Yours sincerely or
Yours faithfully. If you read the sample writing answers on the OET website you can see many examples
of OET letter structure.
WRITING TASK FOR OET 2.0
50 MEDICAL WRITING TASK
TIME ALLOWED: READING TIME: 5 MINUTES Task 1
WRITING TIME: 40 MINUTES

Read the case notes below and complete the writing task which follows.
notes:
Hospital: St. Mary’s Public Hospital, 32 Fredrick Street, Proudhurst
Patient Details: Ms Bethany Tailor
Next of Kin: Henry Tailor (father, 65) and Barbara Tailor (mother, 58)
Admission date: 01 March 2018
Discharge date: 18 March 2018
Diagnosis: Schizophrenia
Past medical history:
 Hypertension secondary to fibromuscular dysplasia
 Primary hypothyroidism Levothyroxine 88 mcg daily
Social background:
 Unemployed, on disability allowance for schizophrenia.
 History of polysubstance abuse, mainly cocaine and alcohol. Last used cocaine 28/02/18:

Admission 01/03/2018:
 Patient self-admitted: decompensated schizophrenia

Medical background:
 Not compliant with medications.
 Admitted for auditory command hallucinations telling patient to harm self.
 Visual hallucinations – shadow figures with grinning faces.
 Delusion – personal connections to various political leaders.

01/03/2018 –
 agitated and aggressive, responding to internal stimuli with thought blocking and latency.
 Commenced antipsychotic meds (rispoderone).
10/03/2018:
 Patient ceased reporting auditory or visual- hallucinations.
 Less disorganised thinking.
 No signs of thought blocking or latency.
 Able to minimise delusions and focus on activities of daily living.

Nursing management:
 Assess for objective signs of psychosis.
 Redirect patient from delusions.
 Ensure medical compliance.
 Help maintain behavioral control, provide therapy if possible.

Assessment:
 Good progress, chronic mental illness, can decompensate if not on medications or abusing
substances. Insight good, judgment fair.

Discharge plan:
 Discharge on Risperidone 4g nightly by mouth.
 Risperidone 1 milligram available twice daily p.r.n for agitation or psychosis.
 back to apartment with follow-up at Proudhurst Mental Health Clinic

Writing Task:
Ms. Bethany Tailor is a 35-year-old patient in the psychiatric ward where you are working as a
doctor

Using the information given in the case notes, write a discharge letter to the patient’s primary care
physician, Dr. Giovanni DiCoccio, Proudhurst Family Practice, 231 Brightfield Avenue, Proudhurst

In your answer:
● Expand the relevant case notes into complete sentences
● Do not use note form
● Use correct letter format

The body of your letter should be approximately 200 words. Use correct letter format.
Dr. Giovanni DiCoccio
Proudhurst Family Practice
231 Brightfield Avenue
Proudhurst

19/03/2018

Dear Dr. DiCoccio,

Re: Bethany Tailor, 35 years of age

Your patient, Ms Tailor, admitted herself on 1 March 2018 with decompensated schizophrenia. She
is now ready for discharge and follow-up at your clinic.

On admission, she was experiencing significant thought disorder, including thought blocking and
latency. She was also exhibiting delusions and experiencing auditory command and visual
hallucinations.

During her stay in hospital Ms Taylor was placed back on her medications, and her mental condition
has stabilised and she is able to focus on her activities of daily living. Her insight is now good and
judgment fair. Her nursing management in the hospital focused on compliance with her
antipsychotic medications, behavioral control, and therapy. Since 10 March, she has not reported
visual or auditory hallucinations.

Ms Tailor is on oral Risperidone 4mg nightly. Additional oral risperidone 1mg can be administered as
needed twice daily for agitation or psychosis. She will be discharged from the hospital to her
apartment where she lives alone. She will follow-up with you in order to continue her treatment of
chronic schizophrenia and to avoid non-compliance of her medications or substance abuse.
If you have any queries, please contact me.

Yours sincerely,
Doctor
[183 words]
TIME ALLOWED: READING TIME: 5 MINUTES Task 2
WRITING TIME: 40 MINUTES
Read the case notes below and complete the writing task which follows.
notes:
Hospital: Fairbanks Hospital, 1001 Noble St, Fairbanks, AK 99701
Name: Mrs Sally Fletcher
Date of Birth: 3/10/1993
Marital status: Married, 5 years
Appointment date: 25/03/2018
Diagnosis: Endometriosis
Past medical history:
 Painful periods 3 years
 Wants children, trying 1 year ++

Social background:
 Accountant, regular western diet.
 Exercises 3 x week local gym

Medical background:
 Frequent acute menstrual pain localised to the lower left quadrant.
 Pain persists despite taking OTC = naproxen.
 Shy discussing sexual history.
 Occasional constipation, associated with pain in lower left quadrant.
 Trans-vaginal ultrasound showing 6cm cyst, likely of endometrial origin.
 Patient recovering post op from laparoscopic surgery(25/03/2018) – nocomplications

Post op care: Keep incisions clean and dry.

Mobility post op:

 Showering is permitted 26/03/2018
 Driving is prohibited when on analgesics.
 Driving can be resumed 24-48 hrs after final dose analgesics.
 Sexual activity can be resumed 2 weeks post op.
Nursing management:
 Encourage oral fluids.
 Patient may return to regular diet.
 Ambulation encouraged as per patient tolerance.

Medical progress
 Afebrile. Hct, Hgb, Plts, WBC, BUN, Cr, Na, K, Cl, HCO3, Glu all within normal limits.
 Patient sitting comfortably, alert, oriented × 4 (person, place, time, situation).

Assessment:
 Good progress overall.
Discharge plan:
 Patient to be discharged when can eat, ambulate, urinate independently.
 Patient must be discharged to someone who can drive them home.

Writing Task:
You are a first year resident in a surgical ward. Sally Fletcher is a 25-year-old woman who has
recently undergone surgery. You are now discharging her from hospital.

Using the information given to you in the case notes, write a letter of discharge to the patient’s
GP, Dr Stevens, Mill Street Surgery, Farnham,GU10 1HA.

In your answer:
● Expand the relevant case notes into complete sentences
● Do not use note form
● Use correct letter format

The body of your letter should be approximately 200 words. Use correct letter format
Dr Stevens
Mill Street Surgery
Farnham
GU10 1HA
25 March 2018

Dear Dr Stevens,

Re: Mrs Sally Fletcher D.O.B 3/10/1993

Your patient, Sally Fletcher, was admitted to the surgical ward of Fairbanks Memorial Hospital on 25
March 2018 for the purpose of laparoscopic surgery to treat an endometrial cyst. She is now ready
for discharge into the care of her husband.
When admitted, Sally had been suffering from painful periods over the past 3 years, which she had
been attempting to treat with naproxen, but the pain persisted. An ultrasound scan revealed a cyst
had formed in her abdomen. She arrived at the ward this morning and underwent
laparoscopic surgery, which successfully located and removed a 6cm cyst from her abdomen without
complication.
She has been advised to keep the incision sites clean and dry. She has received narcotic pain
medication and has been advised that she is unable to drive while taking this medication. You should
monitor her progress, and advise when to cease taking this medication. She may resume driving 24-
48 hours after the last dose is taken.
Sally may resume her normal diet today, and is encouraged to drink plenty of fluids. She is also
encouraged to walk as much as she can tolerate.
Sexual activity can resume in two weeks.
If you have any questions please feel free to contact me.

Yours sincerely,

Doctor
[194 words]
TIME ALLOWED: READING TIME: 5 MINUTES Task 3
WRITING TIME: 40 MINUTES
Read the case notes below and complete the writing task which follows.
notes:
Office: First Family Primary Care, 3959 Abalone Lane, Omaha
Patient Details
Name: Tabitha Taborlin (Ms). Marital status: Single. Next of kin: Gregory Taborlin (69, father).
Date seen: 08 April, 2018
Diagnosis: Type 1 diabetes mellitus

Past medical history:

 Essential hypertension
 Type 1 diabetes mellitus (non-compliant with insulin regimen)
 Multiple episodes of diabetic ketoacidosis (DKA)

Social background:
 School teacher, lives alone in apartment
 Does not exercise, BMI 18.2 (underweight - 48kg)
 Smokes moderately (2 cigs daily)

Medical background:
 Long history of Type 1 diabetes (since 7 y.o.) and noncompliance with insulin regimen.
 On 45 units Lantus nightly and preprandial correctional scale Humalog with 12 unit nutritional
baseline.
 02/04/2018: admitted DKA (glucose 530 mmo/L) IV fluids and insulin administered.
Discharge stable - HbA1c.
Appointment today:
 Doing well since discharge.
 Still not using insulin. Has insulin available.
 Not following recommended diet.
 Discussed diabetes education, necessity of glucose testing, insulin administration, smoking
 cessation education.
 Discussed microvascular/macrovascular complications of diabetes.
Plan:
 Discharge today – provide educational pamphlets and refills for Lantus and Humalog.
 Referral to endocrine specialist for stricter glycemic control and possible insulin pump.
 Follow-up in 1 month

Writing Task:
You are a physician OR at a family medical practice. Ms Tabitha Taborlin is a 45-yearold patient at
your practice.

Using the information given in the case notes, write a referral letter to Dr. Sharon Farquad,
Endocrinologist at Endocrine Specialists and Associates, 115 Burke St. Omaha.

In your answer:
● Expand the relevant case notes into complete sentences
● Do not use note form
● Use correct letter format

The body of your letter should be approximately 200 words. Use correct letter format.
Dr. Sharon Farquad
Endocrinologist
Endocrine Specialists and Associates
115 Burke St.
Omaha

08/04/2018

Dear Dr. Farquad

Re: Tabitha Taborlin, 45 years of age

Thank you for seeing Ms Tablorin as a new patient at Endocrine Specialists and Associates. She is a
45 year old female with a past medical history of essential hypertension and uncontrolled Type 1
diabetes mellitus.

Ms Tablorin was seen at my clinic today as a follow-up from a hospital admission for diabetic
ketoacidosis with a glucose measure of 530 mmol/L. She has had multiple prior hospitalisations for
the same issue. She also has a long history of being noncompliant with her insulin medications,
which are 45 units of Lantus nightly, and preprandial correction scale Humalog with 12 units of
nutritional baseline. Her HbA1c is 11.0%.

She has been educated multiple times on diabetes risks and complications, regarding her insulin
regimen, exercise, diet, and tobacco cessation. However, she has continued to ignore these
recommendations and her condition has progressively worsened. It is my recommendation that she
seek a higher level of care, thus I refer her to your practice. Ms Tablorin would likely benefit from a
stricter insulin regimen and glycemic monitoring, as well as an insulin pump for reliability of
medication administration.

If you have any queries, please contact me.

Yours sincerely,

Doctor
[183 words]
TIME ALLOWED: READING TIME: 5 MINUTES Task 4
WRITING TIME: 40 MINUTES
Read the case notes below and complete the writing task which follows.
notes:
Today’s Date 07/11/10
Patient History
Mr David Taylor, 38 years old, married, 3 children
Landscape Gardener
Runs own business.
No personal injury insurance
Active, enjoys sports
Drinks 1-2 beers a day. More on weekends.
Smokes 20-30 cigarettes/day

P.M.H-Left Inguinal Hernia Operation 2008

12/08/10
Subjective
C/o left knee joint pain and swelling, difficulty in strengthening the leg.
Has history of twisting L/K joint 6 months ago in a game of tennis.
At that time the joint was painful and swollen and responded to pain killers.
Finds injury is inhibiting his ability to work productively.
Worried as needs regular income to support family and home repayments.

Objective
Has limp, slightly swollen L/K joint, tender spot on medial aspect of the joint and no effusion.
Temperature- normal
BP 120/80
Pulse rate -78/min

Investigation - X ray knee joint

Management
Voltarin 50 mg bid for 1/52
Advise to reduce smoking
Review if no improvement.
25/8/10
Subjective
Had experienced intermittent attacks of pain and swelling of the L/K joint
No fever
Unable to complete all aspects of his work and as a result income reduced
Reduced smoking 15/day

Objective
Swelling +
No effusion
Tender on the inner-aspect of the L/K joint
Flexion, extension – normal
Impaired range of power - passive & active

Diagnosis ? Injury of medial cartilage

Investigation – ordered MRI

Management
Voltarin 50mg bid for 1 week
Review after 1 week with investigations

07/11/10
Subjective
Limp still present
Patient anxious as has been unable to maintain full time work.
Desperate to resolve the problem
Weight increase of 5kg

Objective
Pain decreased, swelling – no change
No new complications
MRI report – damaged medial cartilage

Management Plan
Refer to an orthopaedic surgeon, Dr James Brown to remove damaged cartilage in order to prevent
future osteoporosis. You have contacted Dr Brown’s receptionist and you have arranged an
appointment for Mr Taylor at 8am on 21/11/10
Writing Task:
You are the GP, Dr Peter Perfect. Write a referral letter to Orthopaedic Surgeon, Dr. James Brown:
1238 Gympie Road, Chermside, 4352.

In your answer:
● Expand the relevant case notes into complete sentences
● Do not use note form
● Use correct letter format

The body of your letter should be approximately 200 words. Use correct letter format.
Dr. James Brown
1238 Gympie Rd
Chermside, 4352

07/11/10

Dear Dr. Brown,

Re: David Taylor

Thank you for seeing this patient, a 38-year-old male who has a damaged cartilage in the left knee
joint. He is self-employed as a landscape gardener, and is married with 3 children.

Mr. Taylor first presented on 12 August 2010 complaining of pain and swelling in the left knee joint
associated with difficulty in strengthening the joint. He initially twisted this joint in a game of tennis
6 months previously, experiencing pain and swelling which had responded to painkillers.
Examination revealed a slightly swollen joint and there was a tender spot in the medial aspect of the
joint. Voltarin 50mg twice daily was prescribed.

Despite this treatment, he developed intermittent pain and swelling of the joint. The x-ray showed
no evidence of osteoarthritis. However, the range and power including passive and active
movements was impaired. An MRI scan was therefore ordered and revealed a damaged medial
cartilage.

Today, the pain was mild but the swelling has not reduced. Mr Taylor is keen to resolve the issue as
it is affecting his ability to work and support his family.
In view of the above I believe he needs an arthroscopy to remove the damaged cartilage to prevent
osteoarthritis in the future.

Yours sincerely,

Doctor

[200 words]
TIME ALLOWED: READING TIME: 5 MINUTES Task 5
WRITING TIME: 40 MINUTES

Read the case notes below and complete the writing task which follows.
notes:
Assume Today's Date: 01/06/10
Patient History
Tom Cribb D.O.B: 23/5/82
Unemployed – builder’s labourer recently made redundant because of lack of work
Married/no children
Wife works full time as shop assistant
No hobbies
Smokes 5-6 cig/day, drinks 2-5u of alcohol per week
Father has hypertension
Mother died at 60 due to breast cancer
No known allergies

12/05/10
Subjective
Very severe pain in lower R abdomen for 3 hrs, radiated to groin, nausea, no vomiting
No red colour urine - frequency normal
No history of trauma, No fever
Anxious about finding new job ASAP – has to make regular home mortgage repayments
Objective
BP: 120/80
PR: 80 BPM
Ab-mild tenderness in lower abdo, no guarding and rebound

Plan
Diagnosis? Ureteric colic due to renal stone
Diclofenac sodium 50mg suppository dose given and 50mg b.i.d. for 5 days
Advised to drink moderate amount of fluid with regular exercise, especially walking for 2-3 days
Review after 2 days with IVP report, UFR report
14/05/10
Subjective
No pain, no new complaints
Objective
IVP-L/kidney-nl R/enlarged kidney which was ectopic. No evidence of stones
UFR-few red cells
Advised to drink more fluid especially in hot weather
Ordered ultrasound of abdomen to exclude any kidney pathology and review in 2 weeks

01/06/10
Subjective
Had mild R sided lower abdominal pain 5 days ago, responded to Panadol
Ultrasound-severe hydronephrosis? Mass attached to the liver, L/kidney, spleen, pancreases normal
Rehired as builder’s labourer on new job due to start in two weeks -keen to get back to work.
Objective
BP: 140/90
PR: 98 regular
Ab-mass in R/lower abdominal area. RDE-felt a hard mass & kidney situated below normal site.
Hydronephrosis +
Plan
Refer to a urologist for further investigation including CT scan and assessment.

Writing Task:
You are a General Practitioner at a Southport Clinic. Tom Cribb is your patient.
Using the information in the case notes, write a letter of referral to urologist for CT scan and
assessment. Address the letter: Dr B Comber, Urologist, Southport Hospital, Gold Coast

In your answer:
● Expand the relevant case notes into complete sentences
● Do not use note form
● Use correct letter format

The body of your letter should be approximately 200 words. Use correct letter format.
Dr. B. Comber
Urologist
Southport Hospital
Gold Coast

June 1 2010

Dear Doctor,

Re: Mr. Tom Cribb DOB: 23/05/1982

I am writing to refer Mr. Cribb, a married and unemployed male who has a renal mass.

Mr. Cribb first came to see me on the 12/05/10 complaining of severe pain in the right lower
abdomen which was radiating to the groin. It was not associated with urinary or gastrointestinal
symptoms, trauma or fever. His vital signs were normal and his lower abdomen was mildly tender.
He was prescribed diclofenac suppositories 50mg twice a day for 5 days. He was adviced to drink
fluids and walk regularly. The IVP report on the 14/05/10 showed an enlarged and ectopic right
kidney, no stones were reported and the UFR had a few red cells. With regard to his risk factors, he
is a smoker and drinks alcohol. His father has hypertension and his mother died from breast cancer.

On today’s consultation, he complained of right lower abdominal pain of 5 day duration which was
relieved by Panadol. His vital signs were normal and a mass was palpated in the right abdominal
area. His right kidney was below the normal site. The ultrasound showed severe hydronephrosis and
a mass attached to the liver. He was advised to undergo further CT scan investigations.

I would appreciate your assessment to Mr. Cribb’s urologic problem.

Yours sincerely,

Doctor
[209 words]
TIME ALLOWED: READING TIME: 5 MINUTES Task 6
WRITING TIME: 40 MINUTES

Read the case notes below and complete the writing task which follows.
notes:
Today’s Date 10/02/10
Patient History
Alison Martin , Female ,28 year old, teacher.
Patient in your clinic for 10 years
Has 2 children, 4 years old and 10 months old, both pregnancies and deliveries were normal.
Husband, 30 yr old, manager of a travel agency. Living with husband’s parents.
Has a F/H of schizophrenia, symptoms controlled by Risperidone
Smoking-nil
Alcohol- nil
Use of recreational drugs – nil

09/01/10
Subjective
c/o poor health, tiredness, low grade temperature, unmotivated at work, not enjoying her work. No
stress, loss of appetite and weight.
Objective
Appearance- nearly normal
Mood – not depressed
BP- 120/80
Pulse- 80/min
Ab, CVS, RS, CNS- normal

Management
Advised to relax, start regular exercise, and maintain a temperature chart. If not happy follow up
visit required
20/01/10
Subjective
Previous symptoms – no change
Has poor concentration and attention to job activities, finding living with husband’s parents difficult.
Says her mother-in-law thinks she is lazy and is turning her husband against her. Too tired to do
much with her children, mother-in-law takes over. Feels anxiety, poor sleep, frequent headaches.

Objective
Mood- mildly depressed
Little eye contact
Speech- normal
Physical examination normal

Tentative diagnosis
Early depression or schizophrenia

Management plan
Relaxation therapy, counselling
Need to talk to the husband at next visit
Prescribed Diazepam 10mg/nocte and paracetamol as required
Review in 2/52

10/02/10
Subjective
Accompanied by husband and he said that she tries to avoid eye contact with other people, reduced
speech output, impaired planning, some visual hallucinations and delusions for 5 days

Objective
Mood – depressed
Little eye contact
Speech – disorganised
Behaviour- bizarre
BP 120/80 , Pulse- 80
Ab, CVS, RS, CNS- normal
Probable diagnosis
Schizophrenia and associated disorders

Management plan
Refer to psychiatrist for assessment and further management.

Writing Task:
You are the GP, Dr Ivan Henjak. Write a referral letter to Psychiatrist, Dr. Peta Cassimatis: 1414
Logan Rd, Mt Gravatt, 4222.

In your answer:
● Expand the relevant case notes into complete sentences
● Do not use note form
● Use correct letter format

The body of your letter should be approximately 200 words. Use correct letter format.
Dr. Peta Cassimatis
1414 Logan Rd
Mt Gravatt, 4222

10/02/12
Dear Doctor,

Re: Alison Martin

I am writing to refer Mrs. Martin, a 28-year-old married woman, who is presenting with symptoms
suggestive of schizophrenia.

Mrs. Martin has been a patient at my clinic for the last 10 years and has a family history of
schizophrenia. She is a teacher with two children, aged 4 years and 10 months, and lives with her
husband’s parents.

She first presented at my clinic on 9 January 2012 complaining of tiredness, a lack of motivation at
work and a low grade fever. On review after ten days, she did not show any improvement. She
displayed symptoms of paranoia and was suffering from poor sleep, anxiety and frequent
headaches. In addition, she was mildly depressed with little eye contact. Relaxation therapy and
counselling were started and Diazepam 10 mg at night was prescribed based on my provisional
diagnosis of early depression or schizophrenia.

She presented today accompanied by her husband in a depressed state, showing little eye contact,
bizarre behaviour and disorganised speech. Despite my management, her symptoms have continued
to worsen with a 5-day history of reduced speech output, impaired planning ability as well as some
visual hallucinations and delusions.

In view of the above, I would appreciate your attention to this patient.

Yours sincerely,

Doctor

[204 words]
TIME ALLOWED: READING TIME: 5 MINUTES Task 7
WRITING TIME: 40 MINUTES

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

notes:
Today's Date 16.02.13
Patient History
Miss Cathy Jones - 25 year old single woman
Occupation - receptionist
Family history of deep vein thrombosis
On progesterone-only pill (POP) for contraception
No previous pregnancies

15.02.13
Subjective
Presents to GP surgery at 7 pm, after work
Complains of lower abdominal pain since the evening before, worse in right iliac fossa
Unsure of last menstrual period, has had irregular bleeding since starting
POP 2 months ago, New partner for past 2 months
No bladder or bowel symptoms

Objective
Mild right iliac fossa tenderness, no rebound / guarding
Apyrexial, pulse 88, BP 110/70
Vaginal examination - quite tender in right fornix. No masses
Assessment
Non-specific abdo pain
Plan: Asks her to return in morning for blood test and reassessment

16.02.13
Subjective
Pain has worsened overnight. Now severe constant pain.
Some slight vaginal bleeding overnight also.
Felt faint while waiting in reception.
On questioning, has left shoulder-tip pain also.
Objective
Very tender in the right iliac fossa, with guarding and rebound tenderness
Apyrexial, Pulse 96, BP 110/70
On vaginal examination, has cervical excitation and markedly tender in the right fornix.
Pregnancy test result positive
Urine dipstick clear

Assessment
Suspected ectopic pregnancy
Plan: You ring the on duty Gynaecology Registrar and ask for urgent assessment, and are instructed
to send her to the A&E Department with a referral letter.

Writing Task:
You are the GP, Dr Sally Brown. Write Referral letter to the Gynaecology Registrar at the Spirit
Hospital, South Brisbane. Ask to be kept informed of the outcome.

In your answer:
● Expand the relevant case notes into complete sentences
● Do not use note form
● Use correct letter format

The body of your letter should be approximately 200 words. Use correct letter format.
Gynaecology Registrar
A&E Department
Spirit Hospital
South Brisbane

16/02/13

Dear Doctor,

Re: Cathy Jones

Thank you for seeing this 25-year-old woman, who I suspect has an ectopic pregnancy.

This is her first pregnancy. Ms. Jones presented to the surgery yesterday evening with vague lower
abdominal pain. She started the progesterone-only pill for contraception two months ago, when she
started a new relationship, and has had some irregular bleeding since then. Therefore, she is unsure
of her exact last menstrual period. Yesterday, she was mildly tender only and her observations were
normal.

However, on review this morning her pain had worsened overnight, she is very tender in the right
iliac fossa, with rebound and guarding, and on vaginal examination there is cervical excitation, and
marked tenderness in the right fornix. Her pregnancy test is positive.

I am concerned that she may have an ectopic pregnancy, and would appreciate your urgent
assessment.

Please keep me informed of the outcome.

Yours sincerely,

Doctor
TIME ALLOWED: READING TIME: 5 MINUTES Task 8
WRITING TIME: 40 MINUTES

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

notes:
Today's Date 25.08.12
Patient History
James Warden
DOB 05.07.32
Regular patient in your General Practice

09.07.12
Subjective
Wants regular check up, has noticed small swelling in right groin.
Hypertension diagnosed 5 years ago, non smoker, regularly drinks 2 – 4 glasses of wine nightly and 1
- 2 glasses of scotch at weekend.
Widower living on his own ,likes cooking and says he eats well.
Current medication noten 50 mg daily, ½ aspirin daily, normison 10mg nightly when required, fifty
plus multivitamin 1 daily, allergic reaction to penicillin.

Objective
BP 155/85 P 80 regular
Cardiovascular and respiratory examination normal
Urinalysis normal
Slight swelling in right groin consistent with inguinal hernia.

Plan
Advised reduction of alcohol to 2 glasses maximum daily and at least one alcohol free day a week.
Discussed options re hernia. Patient wants to avoid surgery.
Advised to avoid any heavy lifting and review BP and hernia in 3 months

25.08.12
Subjective
Had problem lifting heavy wheelbarrow while gardening. Has a regular dull ache in
right groin, noticed swelling has increased.
Has reduced alcohol intake as suggested.
Objective
BP 140/80 P70 regular
Marked increase in swelling in right groin and small swelling in left groin.

Assessment
Bilateral inguinal hernia
Advise patient you want to refer him to a surgeon. He agrees but says he wants a
local anaesthetic as a friend advised him he will have less after effects than with general anaesthetic.

Writing Task:
Write a letter addressed to Dr. Glynn Howard, 249 Wickham Tce, Brisbane, 4001 explaining the
patient's current condition.

In your answer:
● Expand the relevant case notes into complete sentences
● Do not use note form
● Use correct letter format

The body of your letter should be approximately 200 words. Use correct letter format.
Dr. Glynn Howard
Surgical Department
249 Wickham Tce
Brisbane 4001

25/08/2012

Dear Doctor,

Re: Mr. James Warden

DOB 05/07/32

I am referring this patient, a widower, who is presenting with symptoms consistent with a bilateral
inguinal hernia. He has been suffering from hypertension for 5 years for which he takes Noten,
Aspirin and multivitamins. He is allergic to penicillin.

Initially, Mr. Warden presented to me on 09/07/12 for a regular checkup. On examination, he had a
mild swelling of the right groin, his blood pressure was 155/85 and pulse was 80 beats per minute.
Otherwise his condition was normal. He was diagnosed as having an inguinal hernia. I discussed the
possibility of surgery; however, he indicated he did not want an operation. Therefore, I advised that
he avoid heavy lifting and reduce alcohol consumption. A review consultation was scheduled for 3
months later.

Today he returned complaining that his right groin had increased in size with a regular dull ache
possibly due to lifting a heavy wheel barrow. The examination revealed a considerable increase in
the swelling in the right groin as well as a mild swelling of the left groin.

Based on my provisional diagnosis of a bilateral inguinal hernia, I would like to refer him for surgery
as early as possible. Please note that he wishes to have the surgery under local anaesthesia.

Yours sincerely,

Dr X (GP)
TIME ALLOWED: READING TIME: 5 MINUTES Task 9
WRITING TIME: 40 MINUTES

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

notes:
Today's Date 08.08.12
Patient History
Dulcie Wood
DOB 15.07.46
New patient in your general practice. Moved recently to be near family.

03.07. 12
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.

17.07.12
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.

08.08.12
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 14/08/12

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
● Use correct letter format

The body of your letter should be approximately 200 words. Use correct letter format.
Dr Vincent Raymond
422 Wickham Tce
Brisbane, 4001

08/08/12

Dear Dr. Raymond,

Re: Dulcie Wood DOB: 15/07/46

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 over 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
[191- words]
TIME ALLOWED: READING TIME: 5 MINUTES Task 10
WRITING TIME: 40 MINUTES

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

notes:
Today's Date 03.07.12
Patient History
Margaret Leon 01 .08. 52
Gender: Female
Regular patient in your General Practice .

14.01.12
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
25.04.12
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

03.07.12
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
● Use correct letter format

The body of your letter should be approximately 200 words. Use correct letter format.
Dr. William Carlson
First Floor
Ballow Chamber
56 Wickham Tce
Brisbane 4001

03/07/2012

Dear Dr Carlson,

Re: Margaret Leon DOB 01/08/1952

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. as well as being 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 the 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)
[194 words]
TIME ALLOWED: READING TIME: 5 MINUTES Task 11
WRITING TIME: 40 MINUTES

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

notes:
Today's Date 15.08.12
Patient History
Darren Walker
DOB 05.07.72
Regular patient in your General Practice

09.07.12
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 2002.
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
14.08.12
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.
Ask to be informed of the outcome.

In your answer:
● Expand the relevant case notes into complete sentences
● Do not use note form
● Use correct letter format

The body of your letter should be approximately 200 words. Use correct letter format.
Dr. David Brooker (Urologist)
The Urology Department
259 Wickham Tce
Brisbane, 4001

15/08/2012

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 09/07/12 revealed a strong family history of related illness as his 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 14/08/2012, 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 to his condition.

Yours sincerely,

Dr.X

[206 words]
TIME ALLOWED: READING TIME: 5 MINUTES Task 12
WRITING TIME: 40 MINUTES

Read the case notes below and complete the writing task which follows.
notes:
Today’s Date 21/01/12
Patient History
Brendan Cross, Male , DOB: 25/12/2003
Has a sister 6 years, brother 3 years
Mother – housewife
Father – Naval Officer currently on active duty in Indonesia
P.M.H- NAD
Brendan is on 50th percentile for height & weight
Allergy to nuts – hospitalised with anaphylaxis 2 years ago following exposure to peanuts

14/01/12
Subjective
Fever, sore throat, lethargy, many crying spells – all for 3 days.

Objective
Temperature - 39.8°C
Enlarged tonsils with exudate
Enlarged cervical L.N.
Ab - NL
CVS – NL
RR – NL

Probable Diagnosis
Tonsillitis (bacterial)
Management
Oral Penicillin 250mg 6/h, 7days + Paracetamol as required.
Review after 5days if no improvement.
19/1/12
Subjective
Mother concerned – sleepless nights, difficulty coping with husband away – mother-in-law coming
to help.
Brendan not eating complaining of fever, right knee joint pain, tiredness, lethargy – for 2 days

Objective
Temperature - 39.2°C
Hypertrophied tonsils
Cervical limp node – NL
Swollen R. Knee Joint
No effusion
Mid systolic murmur, RR - normal

Investigation
ECG, FBC, ASOT ordered

Treatment
Brufen 100mg tds, review in 2 days with investigation reports

21/1/12
No change of symptoms
ECG – prolonged P-R interval
ESR – increased
ASOT – Increased

Diagnosis
? Rheumatic fever

Plan
Contact Spirit Paediatric Centre to arrange an urgent appointment with Dr Alison Grey, Paediatric
Consultant requesting further investigation and treatment.
Writing Task:
You are GP, Dr Joseph Watkins, Greenslopes Medical Clinic, 294 Logan Rd, Greenslopes, Brisbane
4122. Write a referral letter to Dr Alison Grey, Mater Paediatric Centre, Vulture Street, Brisbane
4101.

In your answer:
● Expand the relevant case notes into complete sentences
● Do not use note form
● Use correct letter format

The body of your letter should be approximately 200 words. Use correct letter format.
Dr. Alison Grey
Mater Paediatric Centre
Vulture Street
Brisbane,4101

21/01/2012

Dear Dr. Grey,

Re: Brendan Cross

Thank you for seeing this 8 year old boy who has demonstrated features consistent with rheumatic
fever. His developmental and past medical history were unremarkable except for an allergy to
peanuts. His mother has difficulty in caring for both his illness and two other small children as his
father is away due to his work as a naval officer.

He presented with symptoms suggestive of acute bacterial tonsillitis on 14/01/12, when fever and
sore throat had occurred over the previous 3 days, associated with lethargy and crying spells. High
temperature (39.8), enlarged tonsils with exudate and cervical lymphadenopathy were found.
Therefore, oral penicillin and paracetamol were prescribed.
Regrettably, he returned on 19/01/12 with worsening symptoms. Fever had persisted with right
knee joint pain. He appeared restless, and was finding it difficult to eat and sleep. Examination
revealed hypertrophied tonsils and a swollen right knee joint without signs of effusion. There was
mid-systolic murmur on heart auscultation. Brufen was prescribed but was not effective. Today,
blood tests results reported elevated erythrocyte sedimentation rate and anti-streptolysin O titre.
An abnormal electrocardiogram indicated prolonged P-R interval.

I believe Brendan needs admission for further investigation and stablisation. I would appreciate your
urgent attention to his condition.

Yours sincerely,

Dr. Watkins

[202 words]
TIME ALLOWED: READING TIME: 5 MINUTES Task 13
WRITING TIME: 40 MINUTES

Read the case notes below and complete the writing task which follows.
notes:
Today's Date 24/08/12
Patient History
Mrs. Jane MacIntyre (DOB 01.03.73)
Two children age 5 and 3
Two miscarriages
First pregnancy
 developed severe pre-eclampsia
 delivered by emergency Caesarean Section at 32 week
 in intensive care for 3 days, required magnesium sulphate
 baby (Sam) weighed 2.1 kg – in Neonatal Intensive Care Unit 2 weeks
 did not require ventilation only CPAP (Continuous Positive Airway Pressure)
Second Pregnancy
 BP remained normal
 baby (Katie) delivered at full term, weighed 3.4kg
Family history of thrombosis
Known to be heterozygous for Factor V Leiden
Treated with prophylactic low molecular weight heparin in two previous pregnancies
No other medical problems
Not on any regular medication
Negative smear 2010

24/08/12
Subjective
Positive home pregnancy test – fifth pregnancy
Thinks she is 8 weeks pregnant
Last menstrual period 26.6.12
Painful urination last three days
Request referral to the Spirit Mother's Hospital for antenatal care and birth.
Objective
BP:120/80
Weight: 60kg
Height: 165cm
Some dysuria for the past 3 days
Urine dipstick: 3+ protein, 2+ nitrites, and 1+ blood
Abdomen soft and non-tender
Fundus not palpable suprapubically

Assessment
Needs antenatal referral to an obstetrician in view of her history of severe pre-eclampsia, Caesarean
Section, and her age
Needs to start folic acid
Needs to start tinzaparine 3,500 units daily, subcutaneously, in view of thrombosis risk.
Suspected urinary tract infection based on her symptoms and the urine dipstick result

Plan
Refer Jane to Dr Anne Childers at the Spirit Mother's Hospital
Commence her on folic acid 400 micrograms daily, advise to continue until 12 weeks pregnant
Arrange routine antenatal blood tests – results to be sent to the Spirit Mother's Hospital when
received
Counsel Jane re antenatal screening for Down's Syndrome in view of her age
Jane elects to have a scan for nuchal translucency, which is done between 11 and 13 weeks
Provide information on Greenslopes Screening Centre.
Prescribe tinzaparine 3,500 units daily subcutaneously
Send a midstream urine specimen to laboratory
Prescribe cefalexin 250 milligrams 6-hourly for five days
Writing Task:
You are GP, Dr. Liz Kinder, at a Family Medical Centre. Write referral letter to Dr. Anne Childers
MBBS FRANZCOG, Consultant Obstetrician, Spirit Mother's Hospital, Stanley Street, South
Brisbane.

In your answer:
● Expand the relevant case notes into complete sentences
● Do not use note form
● Use correct letter format

The body of your letter should be approximately 200 words. Use correct letter format.
Dr. Anne Childers
(MBBS, FRANZCOG)
Consultant Obstetrician
Spirit Mother’s Hospital
Stanley Street
South Brisbane

24/08/12

Dear Dr. Childers,

Re: Mrs. Jane MacIntyre DOB 01/03/73
Thank you for accepting this 39-year-old mother of 2, who is 8 weeks pregnant and has a strong
history of severe pre-eclampsia in her first pregnancy which resulted in an emergency caesarean
section at 32 weeks of gestation. However, her second pregnancy and delivery was normal. In
addition, she has had 2 miscarriages. In view of her age and history, I believe Mrs. MacIntyre needs
urgent specialist assessment and care.
On presentation today, Mrs. MacIntyre reported that she is heterozygous for Factor 5 Leiden and
has a family history of thrombosis. Therefore, I commenced her on trizaparine 3,500 units daily. In
addition, Mrs. MacIntyre complained of difficulty in urination for the previous 3 days and her urine
dipstick test showed presence of a large amount of protein and nitrate along with slight blood.
Therefore, in view of urinary tract infection, cefalexim 250 miligrams 6 hourly daily for 5 days was
prescribed and mid-stream urine test was ordered.

Please note, I have commenced Mrs. MacIntyre on folic acid 400 microgram daily and have advised
her for nuchal translucency scan in order to rule out Down’s syndrome.
I am happy to share her antenatal care with you, as you think appropriate.
Yours sincerely,

Dr. Liz Kinder

General Practitioner

[200 words]
TIME ALLOWED: READING TIME: 5 MINUTES Task 14
WRITING TIME: 40 MINUTES

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

Today’s Date 14.10.12

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

09/10/12
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
12/10/12
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

14/10/12
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 answer:
● Expand the relevant case notes into complete sentences
● Do not use note form
● Use correct letter format

The body of your letter should be approximately 200 words. Use correct letter format.
The Duty Registrar
Emergency Paediatric Unit
Brisbane General Hospital
140 Grange Road
Kelvin Grove, QLD, 4222

14/10/12

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, although she
and her father understand English.

Initially, accompanied by her parents, she presented to me on 9.10.12 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

[208 words]
The Duty Registrar
Emergency Pediatric Unit
Brisbane General Hospital
140 Grange Road
Kelvin Grove QLD 4222

14/10/12

Dear Doctor,

Re: Amina Ahmed

Thank you for urgently seeing this 8-year-old child, who is presenting with features suggestive of
meningococcal meningitis.

She is the first child of a family of 5, which includes her parents and younger siblings. The family
immigrated from Somalia 7 years ago. however, they understand English.

The patient, accompanied by her parents, initially presented on 09/10/12 complaining of fever,
runny nose, mild cough and loss of appetite. On examination, her vitals were normal except for a
temperature of 39.4 Celsius. At that time, neck stiffness or rash were not noticed. After three days,
she reported having constant headaches and lethargy with the deterioration of her earlier
symptoms. Additionally, her temperature was not responding to the antipyretic. Therefore, blood
and urine tests were ordered.

Unfortunately, today, Amina became lethargic and listless. Her parents were worried as she vomited
twice last night and her headaches have been worsening. Examination revealed that she was
severely febrile with a temperature of 40.2 and a pulse rate of 110 per minute. A maculopapular
rash over the legs and neck stiffness were also observed. The blood test showed elevated WBC with
a left shift. As a result, penicillin IV was commenced.

In view of the above, I believe she needs urgent admission.

Yours faithfully,

Doctor

[203 words]
TIME ALLOWED: READING TIME: 5 MINUTES Task 15
WRITING TIME: 40 MINUTES

Read the case notes below and complete the writing task which follows.
notes:
Patient: Anne Hall (Ms)
DOB: 19.9.1965
Height: 163cm Weight: 75kg BMI: 28.2 (18/6/10)

Social History: Teacher (Secondary – History, English)

Divorced, 2 children at home (born 1994, 1996)
Non-smoker (since children born)
Social drinker – mainly spirits

Substance Intake: Nil

Allergies: Codeine; dust mites; sulphur dioxide

FHx: Mother – hypertension; asthmatic; Father – peptic ulcer

Maternal grandmother – died heart attack, aged 80
Maternal grandfather – died asthma attack
Paternal grandmother – unknown
Paternal grandfather – died ‘old age’ 94

PMHx: Childhood asthma; chickenpox; measles

1975 tonsillectomy
1982 hepatitis A (whole family infected)
1984 sebaceous cyst removed
1987 whiplash injury
1998 depression (separation from husband); SSRI – fluoxetine 11/12
2000 overweight – sought weight reduction
2002 URTI
2004 dyspepsia
2006 dermatitis; Rx oral & topical corticosteroids
18/6/10
PC: dysphagia (solids), onset 2/52 ago post viral(?) URTI
URTI self-medicated with OTC Chinese herbal product – contents unknown
No relapse/remittent course
No sensation of lump
No obvious anxiety
Concomitant epigastric pain radiating to back, level T12
Weight loss: 1-2kg
Recent increase in coffee consumption
Takes aspirin occasionally (2-3 times/month); no other NSAIDs

Provisional diagnosis: gastro-oesophageal reflux +/- stricture

Plan: Refer gastroenterologist for opinion and endoscopy if required

Writing Task:
Using the information in the case notes, write a letter of referral for further investigation and
definitive diagnosis to the gastroenterologist, Dr Jason Roberts, at Newtown Hospital, 111
High Street, Newtown.

In your answer:
● Expand the relevant case notes into complete sentences
● Do not use note form
● Use correct letter format

The body of your letter should be approximately 200 words. Use correct letter format.
Dr Jason Roberts
Newtown Hospital
111 High Street
Newtown

18/6/10

Dear Dr Roberts

Re: Ms Anne Hall, DOB 19.9.1965

Thank you for seeing Ms Hall, a 44-year-old secondary school teacher, who is presenting with a two
week history of symptoms of dysphagia for solids, epigastric pain radiating posteriorly to T12 level,
and concomitant weight loss. The symptoms follow a constant course.

Ms Hall believes the problem commenced after an upper respiratory tract infection two weeks ago
for which she self-prescribed an over-the-counter Chinese herbal product with unknown ingredients.
However, she has also recently increased her coffee consumption and takes aspirin 2-3 times a
month.
She has a history of dyspepsia (2004), and dermatitis for which she was prescribed oral and topical
cortisone. There are no apparent signs of anxiety. She has not smoked for the last 15 years. She drinks
socially (mainly spirits), has a family history of peptic ulcer disease and is allergic to codeine. Her BMI
is currently 28.2.

My provisional diagnosis at this point is gastro-oesophageal reflux with possible stricture. I am

therefore referring Ms Hall to you for further investigation.
Thank you for assessment and ongoing management of this woman. If you require any further
information, please do not hesitate to contact me.

Yours sincerely

Doctor
TIME ALLOWED: READING TIME: 5 MINUTES Task 16
WRITING TIME: 40 MINUTES

Read the case notes below and complete the writing task which follows.
notes:
Patient: Mrs Priya Sharma , DOB: 08.05.53 (Age 60)
Residence: 71 Seaside Street, Newtown

Social Background:
Married 40 years – 3 adult children, 5 grandchildren (overseas). Retired (clerical worker).
Family History:
Many relatives with type 2 diabetes (NIDDM)
Nil else signifcant

Medical History:
1994 – NIDDM
Nil signifcant, no operations
Allergic to penicillin
Menopause 12 yrs
Never smoked, nil alcohol
No formal exercise

Current Drugs:
Metformin 500mg 2 nocte
Glipizide 5mg 2 mane
No other prescribed, OTC, or recreational

29/12/13
Discussion:
Concerned that her glucose levels are not well enough controlled – checks levels often (worried?)
Attends health centre – feels not taking her concerns seriously
Recent blood sugar levels (BSL) 6-18 / Checks BP at home
Last eye check October 2012 – OK
Wt steady, BMI 24
App good, good diet
Bowels normal, micturition normal
O/E:
Full physical exam: NAD
BP 155/100
No peripheral neuropathy; pelvic exam not performed
Pathology requested: FBE, U&Es, creatinine, LFTs, full lipid profle, HbA1c
Medication added: candesartan (Atacand) tab 4mg 1 mane
Review 2 weeks

05/01/14 Pathology report received:

FBE, U&Es, creatinine, LFTs in normal range
GFR > 60ml/min
HbA1c 10% (very poor control)
Lipids: Chol 6.2 (high), Trig 2.4, LDLC 3.7

12/01/14 Review of pathology results with Pt Changes in medication recommended

Metformin regime changed from 2 nocte to 1 b.d.
Atorvastatin (Lipitor) 20mg 1 mane added
Glipizide 5mg 2 mane
Review 2 weeks

30/01/14
Home BP in range
Sugars improved
Pathology requested: fasting lipids, full profle

06/02/14 Pathology report received: Chol 3.2, Trig 1.7, LDLC 1.1

10/02/14 Pathology report reviewed with Mrs Sharma

Fasting sugar usually in 16+ (high) range
Other blood sugars 7-8
Refer to specialist at Diabetes Unit for further management of sugar levels
Writing Task:
Using the information in the case notes, write a letter of referral to Dr Smith, an
endocrinologist at City Hospital, for further management of Mrs Sharma’s sugar levels.
Address the letter to Dr Lisa Smith, Endocrinologist, City Hospital, Newtown.

In your answer:
● Expand the relevant case notes into complete sentences
● Do not use note form
● Use correct letter format

The body of your letter should be approximately 200 words. Use correct letter format.
Dr Lisa Smith
Endocrinologist
City Hospital
Newtown

10 February 2014

Dear Dr Smith,
Re: Mrs Priya Sharma
71 Seaside Street, Newtown
DOB 08.05.53

Thank you for seeing Mrs Priya Sharma, a type 2 diabetic. I would be grateful if you would assist with
her blood sugar control.

Mrs Sharma is 60 years old and has a strong family history of diabetes. She was diagnosed with
NIDDM in 1994 and has been successfully monitoring her BP and sugar levels at home since then.
She first attended my surgery on 29/12/13 as she was concerned that her blood sugar levels were no
longer well controlled.

On initial presentation her BP was 155/100 and she said that her blood sugars were running
between 6 and 18. Her medication at that time was metformin 500mg x2 nocte and glipizide 5mg x2
mane.

Mrs Sharma is allergic to penicillin. A pathology report on 05/01/2014 showed HbA1c levels of 10%
and GFR greater than 60ml/min. Her cholesterol was high (6.2).

On 29/12/13, I instituted Atacand 4mg, 1 tablet each morning. Since then her home-monitored BP
has been within range. On 12/01/14, I also prescribed Lipitor 20mg daily, and her lipids have
improved, with cholesterol falling from 6.2 to 3.2.

Mrs Sharma reports that her fasting BSL is in the 16+ range (other blood sugars are 7-8). I am
concerned about her fasting blood sugars, which remain high, and would appreciate your advice.

Yours sincerely,

Doctor
TIME ALLOWED: READING TIME: 5 MINUTES Task 17
WRITING TIME: 40 MINUTES

Read the case notes below and complete the writing task which follows.
notes:
Mrs Toula Athena, 47, married, two children, home duties
Family history
Mother diabetes, died stroke 10 years ago aged 67
Medical history
Unremarkable, no medications
Social History Married 2 children, home duties

11/11/06
Subjective:
4 months thirst, bulimia, nocturia (4 times per night)
lethargy 7 weeks
dizziness

Objective:
Ht. 1.60 Wt. 95kgs.
Pulse 84 reg, BP 160/95
Plan: Arrange investigations – blood sugar, mid stream
urine (MSU)
Dietary advice re weight loss, appropriate foods

16/12/06
Subjective:
Reports has followed diet, no weight loss
Symptoms unchanged
Frequent headaches

Objective:
No weight loss
BP 170/95
Investigation results: blood sugar 11 mmol / l
• no sugar in urine
• albumin in urine + +
Plan:
prescribe antidiabetic and antihypertensive
medications, continue diet

07/01/07
Subjective:
Complains feeling worse
Blurred vision
Sight spots
Objective:
BP 165/90

Plan:
Referral Dr. Haldun Tristan, endocrinologist

Writing Task:
Using the information in the case notes, write a letter of referral to Dr Tristan, an endocrinologist
at Melbourne Endocrinology Centre, 99 Brick Road, East Melbourne 3004. The main part of the
letter should be approximately 180-200 words long.
In your answer:
● Expand the relevant case notes into complete sentences
● Do not use note form
● Use correct letter format

The body of your letter should be approximately 200 words. Use correct letter format.
Dr Haldon Tristan
Melbourne Endocrinology Centre
99 Brick Road
East Melbourne VIC 3004
7 January 2007

Dear Dr. Tristan,

Re: Mrs Toula Athena, 47, married, two children, home duties

Thank you for seeing Mrs Athena who presents today with symptoms consistent with late onset
Diabetes Melitis (DM).

Please note, the patient’s mother suffered from DM and died of a stroke at the age of 67. Mrs.
Athena’s past medical history is unremarkable and she currently takes no medications.

Mrs. Athena initially presented on 11 November last year with a four-month history of thirst,
bulimia and nocturia.

She urinated four times a night. Furthermore, she complained of lethargy during the preceding
seven weeks. At that time she was overweight. Dietary advice was given and relevant
investigations arranged.

On 16 December, the patient re-presented with her symptoms unchanged and raised BP. In
addition, she reported frequent headaches. Her test results showed that her blood sugar was 11
mmol/l and that the albumin in her urine was elevated but without any evidence of sugar.
Antidiabetic and antihypertensive medications were prescribed and she was advised to continue
her diet.

As mentioned above, Mrs. Athena presents today with worsening diabetic symptoms. Moreover,
her vision is blurred and she has sight spots.

I would be grateful for your assessment of this patient. Should you require further information
please contact me directly at my surgery.
Yours sincerely

Doctor
Dr. Haldun Tristan (Endocrinologist)
Melbourne Endocrinology Centre
99 Brick Road
East Melbourne, 3004

Dear Dr. Tristan,

Re: Ms. Toula Athena

I am writing to refer this patient to you in order to rule out diabetes. Ms. Athena is a 47-year-old
housewife. She is married and has 2 children. Her risk factors include: hypertension, obesity,
strong family history (her mother was diagnosed with diabetes and died of stroke 10 years ago),
elevated blood sugar and albuminuria.

Initially, she came to see me two months ago. She had been suffering from thirst, bulimia,
nocturia and dizziness during the previous four months. In addition, she had been lethargic for
the previous 7 weeks. Her blood pressure was elevated at 160/95 mm hg and pulse rate was 84
beats per minute. She was advised to keep on diet in order to reduce weight, blood and urine
tests were ordered.

One month later, her condition did not improve and her weight was unchanged. Due to her
symptoms and test results antidiabetic and antihypertensive medications were prescribed.

Regrettably, today Ms. Athena`s condition deteriorated. She complained of blurred vision and
sight spots. Despite treatment her blood pressure also was elevated at 165/90 mmhg.

I believe she requires admission to the Endocrinology Centre for treatment and stabilization.
Please keep me informed of her condition.

Yours sincerely,

Doctor
TIME ALLOWED: READING TIME: 5 MINUTES Task 18
WRITING TIME: 40 MINUTES

Read the case notes below and complete the writing task which follows.
notes:
Peter Ludovic, 8 years old
22/12/06
Complains of sore throat. Mother reports fever, irritable.
Voice hoarse

O/E:
enlarged tonsils, exudate
Tender, large cervical nodes
T 39.5°

Assessment: Tonsillitis
Plan: Penicillin v 250mg qid 7 days

15/01/07 Mrs.
Ludovic reported son’s urine brown 4 days previously.
Says Peter is lethargic, no report of frequency, trauma or dysuria.
O/E: tonsillar hypertrophy
BP 90/60
Urinalysis – macroscopic haematuria

Assessment:
? post streptococcal nephritis
? urinary tract infection

Plan:
R/V 2 days
Fluids, rest
Tests:
Full Blood Examination (FBE), urea and creatinine
[U&E], electrolytes, mid stream urine [MSU]
micro/culture/sensitivity [M/C/S], Antistreptolysin-O Titre [ASOT] and cell morphology
18/01/07
Peter asymptomatic
O/E: BP 110/90
macroscopic haematuria

Test results:
FBE normal
U&E↑
ASOT↑+++
MSU – 4X 10 # RBC [red blood cells ] of renal origin

Assessment:
post streptococcal nephritis with early renal failure

Plan: Refer to paediatrician

WRITING TASK
Using the information in the case notes, write a letter of referral to Dr Xavier Flannery, a
paediatrician at 567 Church St Springvale 3171.

In your answer:
● Expand the relevant case notes into complete sentences
● Do not use note form
● Use correct letter format

The body of your letter should be approximately 200 words. Use correct letter format.
Dr. Xavier Flannery
Paediatrician
567 Church Street
Springvale, 3171

18 January 2008

Dear Dr. Flannery,

Re: Peter Ludovic, 8 years old

Thank you for seeing Peter who I suspect has post-streptococcal nephritis with early renal
failure.

Initially, Peter presented on 22 December 2006 with symptoms suggestive of acute bacterial
tonsillitis. According to his mother, he had been suffering from sore throat, associated with fever
(39.5), hoarse voice and irritable mood. Enlarged tonsils with exudate and cervical
lymphadenopathy were found, and oral penicillin was prescribed.

On the second examination 15 January 2007, the patient reported blood in urine over the
previous four days, as well as lethargy. Examination revealed hypertrophied tonsils, and urine
analysis showed macroscopic haematuria. Blood pressure was normal.

Today, blood test results reported elevated urea and creatinin, antistreptilysin-O titre, and mid-
stream urine showed red blood cells of renal origin (4x10).

In view of the above signs and symptoms, I would appreciate your urgent assessment and
treatment of this patient.

Yours sincerely,

Doctor
TIME ALLOWED: READING TIME: 5 MINUTES Task 19
WRITING TIME: 40 MINUTES

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

Name Mrs. Larissa Zaneeta, Age 38-years-old

Family and social history
Marketing manager, married,
one child (four-year-old boy).

Medical history
Unremarkable, no medications

11/07/05
Complains of tiredness, difficulty sleeping for 2 months due to work stress
Plans another child in 12 months, currently on oral contraceptive pill (OCP)
O/E:
Appears pale, tired and slightly restless
BP 140/80
No abnormal findings
Assessment: Stress-related anxiety
Plan:
advised relaxation techniques, reduce working hours,
prescribe sleeping tablets tds

15/08/06
Stopped OCP 4 months earlier, still menstruating
Worried
Sleep still difficult, work stress unchanged, not possible to reduce hours
O/E: Tired-looking, slightly teary
Assessment: Work stress, growing anxiety failure to conceive
Plan:
discussed nature of conception – takes time, patience
discussed frequency sexual intercourse
discussed methods – temperature / cycle
18/01/07
Expressed anxiety re failure to conceive, says she's "too old"
sleep still a problem
O/E:
crying, pale, fidgety
Vital signs / general exam NAD
Pelvic exam, pap smear
Assessment: as per previous consultation
Plan:
1-2 Valium b.d.
Suggested she re-present next week accompanied by husband.

25/01/07
Mr. Zaneeta very supportive of having another child
No erectile dysfunction, libido normal
Mrs. Zaneeta unchanged
O/E:
Mr. Zaneeta normal
Plan: Check Mr. Zaneeta's sperm count

02/02/07
Sperm count normal
Plan: Refer for specialist advice

Writing Task:
Using the information in the case notes, write a letter of referral to Dr Elvira Sterinberg, a
gynaecologist at 123 Church St Richmond 3121.

In your answer:
● Expand the relevant case notes into complete sentences
● Do not use note form
● Use correct letter format

The body of your letter should be approximately 200 words. Use correct letter format.
Dr. Elvira Sterinberg
Gynaecologist
123 Church Street
Richmond, 3121

02 February 2007
Dear Dr. Sterinberg,

Re: Mrs. Larissa Zanetta, a 38-year-old woman, marketing manager, married, has one child (a four-
year-old boy) and Mr. Zanetta, her husband
Thank you for seeing my patients who have been trying to conceive for 10 months without any
success.
Initially, Mrs. Zanetta came to see me on 11/07/05 complaining of tiredness and difficulty sleeping
for the previous 2 months due to work stress. She was on oral contraceptive pill at that time and was
planning another pregnancy in 12 months. Her medical history was unremarkable.

The patient demonstrated signs of anxiety, such as paleness, tiredness and slightly elevated blood
pressure (140/80mmhg). Accordingly, relaxation techniques, reducing work hours and sleeping
tablets were recommended.
One year later, Mrs. Zanetta visited me again complaining of failure to conceive since she had
stopped the pill. Sleeping problem and work-related stress persist. Therefore, reassurance was given
and advice regarding nature of conception was provided.

However, on review six months later the patient had not managed to conceive and her anxiety had
increased. As a result, Valium was prescribed 1-2 tablets at night. Pelvic examination was normal
and Pap smear was taken. Next consultation with her husband was organized the following week.

Examination of Mr. Zanetta was unremarkable and sperm count was normal.

I would be grateful if you could take over the further management of this couple.

Yours faithfully,

Doctor
TIME ALLOWED: READING TIME: 5 MINUTES Task 20
WRITING TIME: 40 MINUTES

Read the case notes below and complete the writing task which follows.
notes:
Name Mr Jing ZU
Age 72-year-old man

Family history unremarkable

Medical history
Hypertension 18 years
Ischaemic heart disease 10 yrs
Acute Myocardial Infarction 1999
Congestive Cardiac Failure (CCF) 5 yrs

Medications
Lasix 40mg mane, Enalapril 10mg mane, Slow K TT bd, Nifedipine 10mg tds, Anginine T sl prn

Social History Job:

retired school teacher
Home: married
Activities: gardening
Smoking: no

03/01/07
Subjective:
Angina on exertion – gardening, relief with rest and Anginine
Sleeps two pillows, no orthopnoea
Mild postural dizziness
Objective:
Thin, looks well.
Pulse 84 reg, BP 160/90 lying, 145/80 standing
Jugular Venous Pressure (JVP) + 3 cm
Apex beat not displaced
S1 and S2 no extra sounds nor murmurs
Chest - Bilateral basal crepitations
Abdomen – normal
Ankles mild oedema, pulses present

Assessment: Stable CCF, angina

Plan: Watchful monitoring

15/01/07

Subjective: ↑ dyspnoea, orthopnoea (sleeps on 4 pillows)

↑ ankle oedemano chest pain

Objective:
BP 140/90
JVP + 6 cm
Chest crepitations to mid zones
Heart S1 and S2
Ankles oedema to knees

Assessment: Deteriorating CCF ? cause

Plan: ECG, ↑Lasix 80 mg mane, R/V 2 days

19/01/07

Subjective:
Dyspnoea “feels a bit better”
Angina 10 min episode on mild exertion yesterday

Objective:
JVP + 4 cm
Chest fewer crepitations to mid zones
ECG - ? ischaemic changes anterolaterally

Assessment: ischaemic heart disease

Plan:
Referral Dr. George Isaacson, cardiologist, management of ischaemic heart disease

Writing Task:
Using the information in the case notes, write a letter of referral to Dr Isaacson, a cardiologist
at 45 Inkerman Street Caulfield 3162.

In your answer:
● Expand the relevant case notes into complete sentences
● Do not use note form
● Use correct letter format

The body of your letter should be approximately 200 words. Use correct letter format.
Dr. George Isaacson
Cardiologist
45 Inkerman Street
Caulfield, 3162

19 January 2007

Dear Dr. Isaacson,

Re: Mr. Jing Zu

I am writing to refer Mr. Zu, a 72-years-old retired school teacher, to you. Mr. Zu has been suffering
from ischemic heart disease for ten years, hypertension for 18 years and has had congestive cardiac
failure for five years. He was diagnosed with acute myocardial infarction in 1999. He takes lasix
(40mg), Enalapril (10 mg), Nifedepin (10 mg) and Anginine (as necessary).

The patient first came to see me on 03/01/07 complaining of pain in his chest while gardening and
mild postural dizziness. The pain was easily relieved with rest and Anginine. Stable congestive cardiac
failure with angina was diagnosed, and watchful monitoring was recommended.

On the second examination (15/02/2007) his condition had deteriorated. The patient reported
increased dyspnoea with orthopnoea. The oedema on his ankle had worsened. The examination
revealed slightly increased blood pressure (140/90mmhg), chest crepitation to mid zones, and
jugular venous pressure was doubled (+6cm) compared to the previous visit. Therefore,
electrocardiogram was requested, a higher dose of lasix was prescribed (80mg) and another
review was scheduled two days later.

Today (19/01/2007) the patient’s condition has improved, however, electrocardiogram shows
some ischemic changes anterolaterally.

In view of the above, I appreciate your taking over of this patient.

Yours sincerely,

Doctor
Dr. George Isaacson
Cardiologist
45 Inkerman Street
Caulfield 3162

19th January 2007

Dean Dr. Issacson,

Re: Mr. Jing Zu, Age: 72 years
I am writing to refer Mr. Zu, whose features are consistent with ischaemic heart disease. Your
further comprehensive management would be highly appreciated.

Mr. Zu, is a diagnosed case of hypertension and ischaemic heart disease. Please note, he had a
history of acute myocardial infarction and congestive cardiac failure (CCF).
However, his family history is unremarkable and he is a non-smoker. His current medications are
Lasix, enalapril, nifedipine, slow KTT and Anginine Tsl.

Initially, on 31/01/07, he presented with angina while gardening, which was relieved with rest and
Anginine. On examination. he was found apparently well along with typical signs of CCF. Therefore,
stable CCF with angina was diagnosed and watchful monitoring was recommended.

On 15th of January, his condition had deteriorated with worsened symptoms. Examination findings
revealed raised JVP (from +3 to +6), crepitations up to mid zones of the chest and ankle oedema up
to his knees. Thus, considering deteriorating CCF, Lasix dosage was increased, electrocardiogram
(ECG) was ordered and a review in 2 days was advised.

Today, he reported that he has been feeling better though he had an episode with mild exertion
yesterday. Moreover, his JVP was reduced and lesser crepitations were found on the chest.
Furthermore, ECG showed ischaemic changes anterolaterally.

In view of the above, I would appreciate it if you could manage the patient as you feel appropriate.

Yours sincerely,

Doctor
[225 words]
TIME ALLOWED: READING TIME: 5 MINUTES Task 21
WRITING TIME: 40 MINUTES

Read the case notes below and complete the writing task which follows.
notes:
Today's Date 09/11/17
Patient History
 Somarni Khaze
 DOB 12/04/71
 Works as an operating room nurse at Spirit Hospital
 Married with 4 children 3 girls aged 17,11 and 7 years and a boy aged 12 years
 Has a regular period
 Sister had cancer breast 7 years ago and was treated by mastectomy and axillary clearance
followed by chemotherapy
 Past Hx of right breast lump treated by lumpectomy 5 years ago. Dx Benign lesion
 Does not smoke or drink and not using regular medications.
 Did mammogram 2 years ago which showed no suspicions of malignancy.
22/10/17
Subjective
 Discovered a left breast lump 6/52 ago
 Almond size, not painful and not in size
 No nipple discharge
Objective
 Mildly obese (BMI 31)
 Pulse 74/M regular
 BP 120/80
 CVS, RS, ABD are all normal
 Local examination: left breast shows 2x2 CM breast lump hard , non tender with ill defined
margins
 Palpable mobile axillary lymph nodes
 Rt breast is normal except for the scar from previous surgery
Assessment
 ? cancer breast

Management
 Repeat mammogram and order ultra sound
 Advise patient to review in 2 weeks time

6/11/17
 Pt anxious and worried about results; cannot sleep at night
 BP 150/90 and pulse 88/Min
 U/S shows 18x 16 MM nodule at left breast with variable echogenecety .The mammogram
reveals an area highly suspicious of malignancy at the left breast with multiple nodules at
the axilla
 You counsel the patient about the different options of treatment and you do core biopsy
to confirm the diagnosis
 Prescribe diazepam 10 mg nocte to calm the patient down
 Follow up consultation in 3 days for biopsy result and plan of management.

9/11/17
 Biopsy result shows moderately differentiated invasive ductal carcinoma of the left breast.
 Patient ask to be operated by Breast Surgeon Dr. Alaa Omar who had operated on her
sister before.
 Asked about possibility of immediate reconstructive surgery.

Writing Task:
You are Dr. Tin Aung a GP at Weller Park Medical Centre, 151 Pring St. Weller Park 4121. Write
a referral letter to The Breast Surgeon Dr. Alaa Omar: 1414 Wickham Tce. Spring Hill, 4004.
In your answer:
● Expand the relevant case notes into complete sentences
● Do not use note form
● Use correct letter format

The body of your letter should be approximately 200 words. Use correct letter format.
Weller Park Medical Centre
151 Pring St.
Weller Park 4121
Dr. Alaa Omar
1414 Wickham Tce.
Spring Hill, 4004
09/11/17

Dear Dr. Omar,

Re: Mrs. Somarni Khaze DOB: 12/04/71

I am writing to refer Mrs. Khaze, a 46-year-old married nurse with 4 children who has been
diagnosed with left breast cancer.

Mrs. Khaze is a premenopausal woman whose sister was your patient (you treated her for breast
cancer 7 years ago). She is a non-smoker, non-drinker and not on any regular medications. She has a
history of benign right breast lump which was treated by lumpectomy 5 years ago and her
mammogram was normal 2 years ago.
Initially, she presented to me on 22/10/17 after she had discovered a left breast lump 6 weeks
previously which was not increasing in size . She was overweight with a body mass index of 31 but
her general examinations were normal. However, a local examination revealed a 2x2 cm hard non-
tender nodule in the left breast accompanied by palpable left axillary lymph nodes while her right
breast showed the scar of the previous surgery. I suspected breast cancer and ordered ultrasound
and mammogram. 2 weeks later, she was anxious and worried with sleep disturbance and the
results found a 1.6x 1.8 cm nodule in the left breast which was suspected to be malignant with
multiple axillary lymph nodes. Therefore, I prescribed diazepam 10 mg at night and did a core biopsy
of the nodule.
Today, the biopsy result confirmed the diagnosis of moderately differentiated invasive ductal
carcinoma of the left breast.
I would appreciate your urgent attention to her condition. Please be advised that Mrs. Khaze has
expressed a wish for immediate reconstructive surgery.
Yours sincerely,

Dr. Tin Aung (GP)

[253 words]
TIME ALLOWED: READING TIME: 5 MINUTES Task 22
WRITING TIME: 40 MINUTES

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

Today's Date 20/10/17

You are Dr. Peter Smith, GP covering 3 satellite clinics in a remote mining area of Western
Australia. The nearest tertiary hospital to you is 1250km away in Perth or 2 ½ hours by air
evacuation using the Flying Doctor Service. The nearest poly clinic is in Port Hedland with
radiology and laboratory facilities but it is a 6 hour drive over dirt roads.

Patient History
 Ammar Moustafawy (DOB: 15/1/61) Male
 Divorced and lives alone
 Process Technician at a Copper Mine in the remote Pilbara region of Western Australia
 Works on rotation with 6 weeks on location and 4 weeks off
 Started his present rotation one week ago
 Regular overseas holidays
 Just returned from the Phillipines 2 weeks ago after spending a 2-week vacation
 Enjoys water sports: scuba diving, sailing
 Smokes 20 cigarettes/ day
 Drinks 14 units/week
 Walks half an hour every day
 Hx of typhoid fever, (2009) In hospital for 6 days

Drug history
 Not on regular medication
 No known allergy

Family history
 Father died of natural causes at 85
 Mother hypertensive and diabetic aged 76
 Older sister treated for cancer breast when she was 40 YO
18/10/17
Subjective
 Ammar feels unwell, lack of appetite, sense of weakness and lack of energy for 3/7
 Has reduced smoking to 5 cig/day and not drinking for one week
 No vomiting but nauseating and passing motion normally
Objective
 Patient looks tired, not jaundiced
 Weight 89 kg; Height 193 cm
 Pulse 84 regular, BP 130 /80, Temp 37.3° C
 CVS, RS are normal
 Abdominal examination: lax and mobile with no mass or rebound but tender Rt.
hypochondrium with no organomegaly

Assessment and planning

 Prodromal stage of liver disease or mood swings after changing his drinking and smoking habits
 Advise low fat, low protein and rich carbohydrate diet
 Order blood, urine and stool tests
 Prescribe vitamins B complex tablet one TDS and essential forte capsules 2 TDS
 Review in two days for results

20/10/17
Subjective
 Ammar is getting worse
 Cannot tolerate foods only drinks fruit juice and noticed that the urine is getting darker in
color with chills and rigors
Objective
 Temperature 39°C; looks jaundiced and dehydrated
 Abdominal examination shows palpable, tender liver
 No ascitis
 Investigations shows normal stool and 2+ urobilinogin in urine test. Leukocytoses with
increased serum bilirubin and
 deranged liver enzymes (ALT And ALP) in blood tests
Assessment and plan
 Start IV fluids and medicate Rocephin one gram IV BD and Flagyl 500 MG TDS
 Contact Flying Doctor Service for urgent US examination or evacuation
 Result of US shows enlarged liver 20 CM with a 10x10 cm cystic lesion in the Rt. Lobe of liver
 You diagnose liver abscess and arrange referral to surgeon in Perth by Flying Doctor Service
escorted by a registered nurse
 Urgent assessment required including ultrasound guided drainage

Writing Task:
Refer patient to the Surgical Registrar via the Emergency Department of Perth General
Hospital, 268 Brisbane Rd Cottesloe,Western Australia 6542.

In your answer:
● Expand the relevant case notes into complete sentences
● Do not use note form
● Use correct letter format

The body of your letter should be approximately 200 words. Use correct letter format.
Surgical Registrar
via Emergency Department
Perth General Hospital
268 Brisbane Rd
Cottesloe 6542
Western Australia
20/10/17
Dear Doctor,
Re: Mr. Ammar Mostafawy
DOB: 15/01/1961
I am writing to refer Mr. Moustafawy, a 57-year-old male who is a process technician in a copper
mine in the Pilbara region. I suspect he is suffering from liver abscess which requires your urgent
attention and management.
Mr. Moustafawy works on rotation and returned from the Philippines 2 weeks ago. He is a heavy
smoker and heavy drinker but he exercises regularly. Apart from a history of typhoid fever 8 years
ago, he has no significant medical or family history.
Initially, he presented to me 2 days ago because he had not been feeling well and had felt a sense of
weakness and nausea over the previous 3 days. He had stopped drinking and reduced smoking
markedly one week ago. His examination was otherwise normal except for tenderness over the right
hypochondrium. Therefore, blood and urine tests were ordered and he was prescribed vitamin B and
essential forte and advised to increase carbohydrates intake.
Unfortunately, his condition deteriorated over the next 2 days. Today, he is dehydrated, jaundiced
and febrile with chills and rigors. His temperature reached 39°C and his liver is enlarged and tender
as well.His blood test showed leukocytosis and deranged liver functions in addition to increased
urobilinogen in the urine test. The Flying Doctors Agency was contacted and through their ultra
sound machine a 10x10 cm liver abscess could be diagnosed.
I started him on intravenous fluids and antibiotics (Rocephine and Flagyl) and arrangements were
made to evacuate him by the Flying Doctors to your centre.
I would appreciate your urgent attention to his condition as I believe he will need ultrasound-guided
drainage.
Yours Sincerely,

Dr. Peter Smith (GP)

[268 words]
TIME ALLOWED: READING TIME: 5 MINUTES Task 23
WRITING TIME: 40 MINUTES

Read the case notes below and complete the writing task which follows.
notes:
Today's Date 15/3/17
Patient Details:
 Mrs Karen Conway
 Age 32
 Occupation: Solicitor
 Husband William - age 33 - Accountant
 Karen: previous pregnancy 10 years ago, terminated. William does not know about this.
 William: no previous pregnancies.
15/2/17
Subjective
Karen reports:
 Neither she nor William has any significant medical problems.
 Neither smokes
 William drinks quite heavily. Also travels regularly with his job.
 Married for 3 years, and decided to try for a pregnancy in May 2014, when Karen stopped the
pill
 Was on Microgynon 30 for the previous 5 years.
 Periods are regular
 No history of gynaecological problems, or sexually transmitted diseases.
Objective
 Karen overweight BMI 28
 Pulse and BP normal
 Abdo exam normal
 Vaginal examination normal
 Cervical smear taken
Assessment
 Trying to conceive for only 18 months but Karen clearly anxious
 Further investigation appropriate
Action Plan
 Order blood tests to confirm that hormone levels are normal and that Karen is ovulating
 Explain it is necessary to see her husband, William
 Make a joint appointment
 Note - Karen anxious that her history of a termination of pregnancy is not revealed to William.

15/3/17
 Karen re-attends, accompanied by her husband William Conway.

Subjective
 Karen states recent home ovulation-prediction test showed positive- likely that she is
ovulating.
 William has no significant medical problems
 Contrary to Karen’s opinion he states only drinks 10 units per week
 William says works away from home approximately 2 weeks out of 4 - not concerned that
Karen hasn’t conceived -thinks they haven't been trying long enough.
 Not keen on being investigated
Objective
 Karen's baseline blood tests normal
 Ovulation test borderline
 Smear test result negative
 William refuses to be examined - doesn't think there is a problem.
Assessment
 Karen more anxious than before - wants to be referred to an infertility specialist. Her sister
recently had IVF treatment.
 William is quite reluctant.
Action Plan
 Suggest William do a semen analysis – pressured by Karen he agrees
 Reassure Karen no obvious risk factors - not unusual to take up to 2 years to conceive
 Karen requests referral to fertility specialist, while waiting for semen analysis results
 Give general advice regarding timing of intercourse
 Suggest Karen lose some weight
 Check Karen taking folic acid, 400 micrograms daily.
Writing Task:
You are Dr Claire Black, GP. Karen Conway has come to consult you as she and her husband have
been trying to conceive for about 18 months without success. She is becoming concerned that
there may be something wrong. Write the referral letter to Dr John Expert MBBS FRANZCOG,
Gynaecologist and IVF Specialist, St Mary's Infertility Centre, Wickham Terrace, Brisbane.

In your answer:
● Expand the relevant case notes into complete sentences
● Do not use note form
● Use correct letter format

The body of your letter should be approximately 200 words. Use correct letter format.
Dr. John Expert, MBBS FRANZCOG
St Mary's Infertility Centre
Wickham Terrace
Brisbane

15/03/17

Dear Dr. Expert,

Re: Karen Conway, 32 years old

William Conway, 33 years old

This couple have requested referral as they have been trying to conceive for approximately 18
months without success. I have tried to reassure them that there is no reason to be concerned yet,
particularly as William works away from home regularly and there are no risk factors in their history.
However, Karen particularly, was anxious to be referred sooner rather than later. Please note, Karen
has previously had a pregnancy terminated, which William is unaware of.

Karen has regular periods and has no history of gynaecological problems or sexually transmitted
diseases. She had been using Microgynon 30 as contraceptive pills for 5 years; however, she stopped
taking them 18 months ago. Her hormone tests are all normal and ovulation confirmed. I did a smear
test on 15/02/17, which was negative and examination then was normal. She is a little overweight,
with a Body Mass Index of 28 and I have advised that she lose some weight. Karen is taking folic acid
400 mcg daily.

William is a non smoker and drinks 10 units per week, although Karen reports that he drinks heavily.
William has no significant medical problems and he declined examination. However, he has agreed
to do na semen analysis, but I don't as yet have the results. I will forward them on in due course.

Thank you for seeing them and continuing with investigations as you think appropriate. I do wish
them success.

Yours sincerely,

Dr. Claire Black (GP)

[235 words]
TIME ALLOWED: READING TIME: 5 MINUTES Task 24
WRITING TIME: 40 MINUTES

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

Today's Date 12/09/17

Patient History
 Arthur Benson
 DOB: 15/04/92
 Computer Programmer
 Regularly works 55 - 60 hr week
 Married with twin boys aged 6 months
 Non-smoker and social drinker
 Father died at 69 due to stroke
 Mother is a diabetic on metaformin
P.M.H.
 Asthma since childhood-on steroid inhaler
 Allergic to penicillin

25/08/17
Subjective
 C/O headache (2/12), mild sensation of pins and needles, no nausea or vomiting
 Had a car accident 3 months ago. Hospitalised and discharged after 24 hrs with no
complications.
 CT scan normal
Objective
 O/E-overweight BMI 32
 Gait-normal, has lumbar lordosis
 Mild weakness in L/hand
 Vision-good
Plan
 Review 2/52
 Panadol 2 tab 4/24 and rest 2/52
 Advise to reduce weight and increase exercise
06/09/17
Subjective
 Feeling better, no new complaints, no worsening of pins and needles sensation
 Has been walking 30 minutes 3 times a week
 Advised to start work and come back if any concern
Objective
 Weight loss 3kg

12/09/17
Subjective
 C/O worsening headaches for 3 days, dizziness, nausea, blurred vision
 Pain not responded to Panadol but noticed mild response to Panadeine Forte
Objective
 No weight change
 Gait-normal
 Could not read 2 line of eye chart
 Odematous optic disk on fundi examination
 BP: 160/70
 PR: 98bpm
 Mild weakness and loss of sensation in medial aspects of L/hand
 Reflexes: Elbow-normal, Wrist- no reflexes
 Diagnosis: subdural haematoma

Writing Task:
You are a General Practitioner at a suburban clinic Arthur Benson and his family are regular
patients. Using the information in the case notes, write a letter of referral to a neurosurgeon for
MRI scan. Address the letter: Dr J Howe, Neurosurgeon, Spirit Hospital, Wooloongabba.

In your answer:
● Expand the relevant case notes into complete sentences
● Do not use note form
● Use correct letter format

The body of your letter should be approximately 200 words. Use correct letter format.
Dr. J. Howe
Neurosurgeon
Spirit Hospital
Wooloongabba

12/09/17

Dear Doctor,

Re: Arthur Benson

DOB: 15/04/1992

I am writing to refer Mr Benson, a married computer programmer and father of 6-month-old twins,
who I suspect has a subdural haematoma.

Mr Benson first presented to me on 25/08/17 complaining that he had been suffering from
headaches for the previous two months as well as a sensation of pins and needles. He was
overweight but his gait and vision were normal. He had mild weakness in the left hand. He was
prescribed Panadol and advised to rest for 2 weeks, reduce weight and increase exercise. He is a
non-smoker and social drinker. He has a past history of asthma, which has been treated with steroid
inhaler since childhood.
He is allergic to penicillin and had a car accident 3 months ago at which time he was hospitalised for
24 hours without complications and his CT scan was normal.

On today’s consultation, he complained of severe headache of 3-day duration with mild response to
Panadeine forte. It was associated with dizziness, nausea and blurred vision. His blood pressure was
160/70, with normal pulse and blurred fundi margins. His gait and elbow reflexes were normal. He
has mild weakness with loss of wrist reflexes and sensation in the medial aspect of the left hand.

I would appreciate your urgent attention to Mr. Benson’s case.

Yours sincerely,

General Practitioner

[214 words]
TIME ALLOWED: READING TIME: 5 MINUTES Task 25
WRITING TIME: 40 MINUTES

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

Today's Date 30/09/17

Patient History
 Mr. Dave Cochrane
 D.O.B 20/11/64
 Smoker: 20 cig/day
 Drinks 12-14u alcohol per week
 No reg exercise
 Retired at 50
 lives with wife
 3 children all married

12/08/17
Subjective
 Shortness of breath
 tightness in chest
 coughing especially at night
 Shortness of breath worse when lying down and feels better when head is raised at end of bed
Objective
 Dyspnoeic
 B/L ankle oedema
 High jugular venous pressure
 Apex beat lateral to mid-clavicular line and in the 6th ICS
 Cardiovascular normal
 Abdomen normal
 Crepitations in lung base
 ECG shows cardiomegaly
 C-xray- features of infection
Plan
 Diagnosed as left ventricular failure
 Broad spectrum antibiotic for 7 days
 Frusemide 40 mg/day
 Digoxin 0.25 mg/day
 Advise to stop smoking and drinking
 Review 14 days later
 Mild tenderness in lower abdo, no guarding and rebound

25/08/17
Subjective
 Feels better
 Reduced cig to 10/day and alcohol to 10u week
Objective
 Mild B/L ankle oedema
 Few crepitations in lung bases
Plan
 Continue Frusemide and Digoxin
 Rest for one week

30/09/17
Subjective
 Presented with severe shortness of breath, chest pain, sweating for 2 hours
 Anxious
Objective
 Dysponic, B/L ankle oedema
 Jugular venous pressure high
 No murmurs
 Apex beat is 6th ICS
 Lateral mid-clavicular line
 BP: 120/60
 PR: 66 BPM
 B/L crepitations in both lung bases
Plan
 Needs admission to Cardiology Unit for stabilisation
Writing Task:
Using the information in the case notes, write a letter of referral to Emergency Department
QE11 Hospital, 249 Wickham Tce,Brisbane, 4001 explaining the patient's current condition.

In your answer:
● Expand the relevant case notes into complete sentences
● Do not use note form
● Use correct letter format

The body of your letter should be approximately 200 words. Use correct letter format.
Emergency Registrar
Emergency Department
QE11 Hospital
249 Wickham Tce.
Brisbane, 4001
30/09/2017
Dear Doctor,

RE: Dave Cochrane D.O.B. 20/11/1964

I am referring Mr.Cochrane, who is suffering from an acute left ventricular failure and requires
admission to your Cardiology Unit in order to stabilise his condition.
Mr.Cochrane retired when he was 50 years old. He smokes 10 cigarettes a day and drinks 10 units of
alcohol per day. He exercises regularly.
On 12/8/2017, Mr.Cochrane presented with night cough, chest tightness and shortness of breath
which was worse when lying down but improved on raising the head at the end of the bed. On
examination, he was dyspneic. There was bilateral leg oedema, high jugular vein pressure , laterally
deviated apex beat which was located in the 6th intercostal space and basal crepitation on the lung
auscultation. These symptoms were indicative of left ventricular failure. Moreover,
electrocardiography revealed cardiomegaly and the chest X-ray showed features of infection.
Consequently, antibiotic, frusemide and digoxin were prescribed for left ventricular failure. An
appointment in 2 weeks was made.
Two weeks later, the patient's condition had partially improved. Therefore, he was advised to
continue his medications and to rest for one week.

Unfortunately today, Mr.Cochrane has been suffering from severe shortness of breath, chest pain
and sweating for the last 2 hours. On examination, he was anxious and dyspneic. His blood pressure
was 120/80 mmhg and his pulse was 66. In addition, the same previous signs of left ventricular
failure were observed.
I would appreciate your urgent assessment of this patient.

Yours sincerely,

Doctor
[233 words]
TIME ALLOWED: READING TIME: 5 MINUTES Task 26
WRITING TIME: 40 MINUTES

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

Today's Date 27/12/17

You are a Psychiatrist at Spirit Hospital Psychiatric Emergency Care Centre (SECC) and Jack Mills
is a patient on the ward.

Patient Details
 Name- Jack Mills, DOB 01/09/1996
 Marital Status: Single
 Admission: 23/11/2017 (Spirit Hospital Psychiatric Emergency Care Centre)
 Discharge: 27/12/2017
 Diagnoses: Paranoid Schizophrenia/Nicotine Dependence

Family History
 Jack's parents separated 4 years ago and divorced 2 years ago
 No other children in the family

Psychosocial History
 Completed high school; above-average student; often involved in school and
extracurricular activities
 He smokes a pack of cigs a day and drinks beer daily. Binge drinking episodes while at
university. He denies any illicit drug use
 He has a keen interest in computers and collected considerable equipment and software,
primarily gifts from his father
 He has been on Disability Support Pension (DSP) since 2016

Medical History
 Nil
Symptoms History
May 14, 2016
 Jack was first admitted to SHPW with a 6-month history of confusion, difficulty concentrating
on his studies, and frequent mood swings. He stopped attending university and was not in
contact with his friends.

Diagnosis: Paranoid schizophrenia

 He was hospitalised for 2 weeks & stabilised on Haldol 20 mg and sodium valproate 125 mg,
daily.
Plan
 Live with his mother in Parramatta (Sydney area)
 Referral to psychiatrist arranged along with weekly group psychotherapy in Spirit Community
Mental Health Service,NSW.
 Discharged 28/5/16

August 2017
 Attempted suicide: A possible stressor was that 1 week ago his mother said about ideas to
remarry in the near future
 Self-harm through deep cut on both wrists
 Hospitalised in ED, surgical tx, under 24hr supervision. Refused to change medication
 His attendance in group psychotherapy was irregular.

November 2017
 He has been increasingly isolated for the past 2 weeks, working on his computer and is very
secretive about what he is doing
 He stopped attending his work program, saying that he had “more important work” to do at
home
 His mother believes he stopped taking medications
 Jack refuses to eat or talk with his mother; is nervous because of his mother’s plans to remarry)
 He was brought to Spirit Hospital Psychiatric Emergency Care Centre (SECC) by his mother on
23/11/17
 He has been irritable, suspicious and stated that he has been hearing multiple voices in his
head for the past week
Hospital progression
 The patient’s sodium valproate was increased to 125 bd and then 250 tds
 His need for intramuscular (IM) medication, or other medication was explained. The patient
fiercely objected about injection, saying, “I am a reliable person, I can always take the
medicine.” The fact is that he has not been very compliant. After much discussion, the patient
has agreed to take 4 mg of Navane IM, qid
 Jack received one-to-one, supportive, and insight-oriented psychotherapy on various issues
(importance of compliance,taking meds, and avoiding alcoholic beverages). His participation
through the program was less than adequate as he could not concentrate and focus, but he
still participated in psychotherapy group

Lab tests
 Serial FBC for had shown WBC ranging from 9.2 to 12. RBC had ranged from 4.88 to 5.5
 Cholesterol was 5.3 mmoll/L
 T4 was 12.1, the next T4 was 10.1 (normal range 10 - 25 pmol/L), T3 was 4, 7(normal range 4.0
– 8.00 pmol/L), TSH has ranged from 1.2 to 1.5 (normal range 0.4-5.0 mIU/L)
 Sodium valproate level was 42 μg/mL (normal range - 50-100 μg/mL)
 Urinalysis - normal

Condition on discharge
 Improving
Ability to manage funds and finances
 Improving
Ability to use good judgment
 Still impaired
Prognosis
 Guarded
Follow-up
 The patient will be living with his mother
 Will be continued on medication (Sodium valproate 250 bd and Navane 1.5 mg IM q. 4 weeks
(the next dose is due on January 16, 2018)
 LFTs and sodium valproate level to be checked annually
 Cholesterol level to be regularly controlled
 Diet: Low cholesterol
 One-to-one psychotherapy
 Advise to abstain from alcohol & give up smoking
 Vocational rehabilitation and "day programs" to improve self-esteem, quality of life,
treatment compliance, and clinical and social stability

Writing Task:
Using the information in the case notes, write a letter to Dr. Twyford, the Psychiatrist at
Parramatta Spirit Community Mental Health Service, NSW, 2345.

In your answer:
● Expand the relevant case notes into complete sentences
● Do not use note form
● Use correct letter format

The body of your letter should be approximately 200 words. Use correct letter format.
Dr. Twyford
Psychiatrist
Spirit Community Mental Health Service
Parramatta
NSW 2345

27/12/2017

Dear Dr. Twyford,

Re: Mr. Jack Mills, DOB 01/09/1995

I am referring this patient, a 22-year-old man who has a history of paranoid schizophrenia.

Jack was initially diagnosed with schizophrenia 18 months ago and has had frequent admissions due
to recurrent episodes of psychosis including an attempted suicide. His compliance has been poor for
medications and structured work programs. With regard to his psychosocial history, he has a history
of nicotine dependence and binge drinking episodes. His parents divorced 2 years ago and he is
currently living with his mother. Furthermore, he has been on disability support pension since 2016.

He was admitted to our hospital on 23/11/2017, with signs of suspiciousness, oversensitivity,

auditory hallucinations and irritable mood. During hospitalisation, sodium valproate and Navane
were used, and psychotherapy was commenced, although his participation was inadequate because
of his difficulties in concentrating. Apart from this, his laboratory tests were unremarkable.

Jack’s condition has generally improved and he will be discharged today. I have advised him to avoid
alcoholic beverages, quit smoking, follow psychotherapy and vocational rehabilitation and have
blood tests annually. Moreover, he will be continued on sodium valproate 250mg twice daily and
Navane 1.5mg every 4 weeks intramuscularly. Please note that the next injection of Navane is on
16/01/2018.

I would appreciate it if you could take over his care for ongoing management.

Yours sincerely,

Psychiatrist
[217 words]
TIME ALLOWED: READING TIME: 5 MINUTES Task 27
WRITING TIME: 40 MINUTES

Read the case notes below and complete the writing task which follows.
notes:
Today's Date 21/02/17
Patient Details
 Sally Webster
 DOB 10/11/00
 High school student

27/12/16

Subjective
 3/12 constipation
 1 firm bowel action every 4 to 5 days
 Diet includes 2 table spoons of bran each morning
 Has tried laxatives
 Otherwise well

Objective
 Wt. 54kg
 BP 100/50
 P 70 reg
 Abdo: lax, no masses
 P.R. exam unremarkable
 Advised to increase vegetable, fibres and fluid intake.

15/02/17
Subjective
 Presents with mother. Mother concerned about Sally’s lack of appetite and loss of weight.
Much fighting at home about
 habits. Sally claims to feel well and can’t see “ what all the fuss is about”. She just isn’t hungry.
Objective
 Wt. 48kg
 Pale, thin
 BP 100/60 Lying and standing
 Abdo and urinalysis unremarkable
Plan
 Review Sally alone
 Tests: FBE/TFT’s U+E/LFT’s

21/02/17
Subjective
 Distant, little eye contact. Feels parents are “overreacting”. Feels ideal weight is 40 kg (
currently 47kg). Denies vomiting.
 Vague about laxative use.
 Test Results: All normal
Assessment
 Anorexia Nervosa
Plan
 Refer to psychiatrist

Writing Task:
Using the information in the case notes, write a letter of referral to the Psychiatrist Dr. Midori
Yabe, 48 Wickham Tce, Spring Hill.

In your answer:
● Expand the relevant case notes into complete sentences
● Do not use note form
● Use correct letter format

The body of your letter should be approximately 200 words. Use correct letter format.
Dr. Midori Yabe
Psychiatrist
48 Wickham Tce
Spring Hill

21/02/17

Dear Dr. Yabe,

Re: Miss Sally Webster

DOB: 10/11/00

I am writing to refer Sally, a 16-year-old high school student who is suffering from anorexia nervosa.

Initially, she came to see me on 27/12/16, complaining of constipation, and requesting strong
laxatives for this problem. Her weight was 54 kg and her vital signs and physical examination were
normal. Her diet included 2 spoons of bran each morning. Therefore, she was advised to increase
vegetables, fibre and fluid intake.

On the 15/02/17 consultation, despite Sally claiming that she did not believe she had a problem,
her mother reported that she was concerned about Sally’s poor appetite, loss of weight and
argumentative behaviour. Her weight was 48 kg and her vital signs, physical examination and
urinalysis were normal. I requested blood samples for blood chemistry and electrolytes.

On today’s consultation, Sally was interviewed alone. She had poor eye contact and she believes
that her parents were overacting about her idea of reducing her weight to 40 kg. She denied
vomiting and she was vague reporting about laxative use. Her weight was 47 kg and her blood
tests were normal.

I would appreciate your urgent assessment of Sally’s case. Please let me know if you need
further information.

Yours sincerely,

Dr. X

[198 words]
TIME ALLOWED: READING TIME: 5 MINUTES Task 28
WRITING TIME: 40 MINUTES

Read the case notes below and complete the writing task which follows.
notes:
:
Mrs May Hong is a 43-year-old patient in your general practice.

07/02/2014
Subjective:
 Noted a productive cough over last 3/7
 No dyspnoea or pain
 Feverish
 Continues to smoke 10 cigarettes/day

History:
 Rheumatic carditis in childhood, resulting in mitral regurgitation & atrial fibrillation (AF)

Objective: Looks tired

 T: 38 ̊C
 P: 80, AF
 BP: 140/80
 Ear, nose, throat (ENT) – NAD
 Moist cough
 Scattered rhonchi through chest, otherwise OK
 Apical pansystolic murmur

Assessment:
 Acute bronchitis; cigarettes increase condition severity ++
Plan: Advised – cease smoking
 Amoxycillin 500mg; orally t.d.s.
 Other medications unchanged (digoxin 0.125mg mane, warfarin 4mg nocte)
 No known allergies (NKA)
 Review 2/7
 Check prothrombin ratio next visit
09/02/2014

Subjective:
 Cough increase, thick yellow phlegm
 Feels quite run-down
 Not dyspnoeic
 Taking all medications
 No cigarettes for last 2 days

Objective:
 Looks worn-out
 T: 38.5 ̊C
 P: 92, AF
 BP: 120/80
 Mild crackles noted at R lung base posteriorly
 Occasional scattered crackles. Otherwise unchanged

Assessment:
 Bronchitis increase severity , early R basal pneumonia
Plan:
 Sputum sample for microscopy and culture (M&C)
 FBE, chest X-ray
 Chest physiotherapy
 Prothrombin ratio today (result in tomorrow)
 Review tomorrow

10/02/2014
Subjective:
 Brought in by son
 Quite a bad night
 Symptoms
 Pleuritic R-sided chest pain, febrile, dyspnoea
 Prothrombin ratio result 2.4 (target 2.5-3.5)
Objective:
 Unwell, tachypnoeic
 T: 38 ̊C
 P: 110, AF
 BP: 110/75
 Jugular venous pressure (JVP) not elevated
 R lower lobe dull to percussion with overlying crackles
 L basal crackles present
 Pansystolic murmur is louder
 M&C: gram-positive streptococcus pneumoniae, sensitive – clarithromycin & erythromycin
 Amoxicillin resistant
 Chest X-ray: Opacity R lower lobe
 FBE: Leukocytosis 11.0 x 10 9/L

Assessment:
 R lower lobar pneumonia

Plan:
 Urgent hospital admission. Spoke with Dr Roberts, admitting officer, Newtown Hospital Ambulance
transport organised

Writing Task:
Using the information given in the case notes, write a letter of referral to Dr L Roberts, the Admitting
Officer at Newtown Hospital, 1 Main Street, Newtown, for advice, further assessment and treatment.

In your answer:
● Expand the relevant case notes into complete sentences
● Do not use note form
● Use correct letter format

The body of your letter should be approximately 200 words. Use correct letter format.
Dr L Roberts
Admitting Officer
Newtown Hospital
1 Main Street
Newtown

10 February 2014

Dear Dr. Roberts,

Re: Mrs May Hong

Thank you for seeing this 43-year-old patient with right lower lobar pneumonia for assessment.
Mrs Hong has a past history of rheumatic carditis, with resultant mitral regurgitation and atrial
fibrillation. Her usual medications are digoxin 0.125mg mane and warfarin 4mg nocte. She has no
known allergies. Her last prothrombin ratio taken on 09/02 was 2.4.

Today, she presents with a six-day history of productive cough with associated fever and lethargy.
This was treated initially with oral amoxycillin (ineffective) and then chest physiotherapy, but today
she has deteriorated with tachypnoea and right pleuritic chest pain. The right lower lobe is dull to
percussion and crackles are present in both lung fields, worst at the right base. Her temperature is
38 ̊C, BP 110/75,pulse 110 (irregular) and her usual pansystolic murmur is louder than normal.
Sputum M&C showed gram-positive streptococcus pneumoniae. The X-ray showed opacity in the
right lower lobe.

I believe her rapid deterioration warrants inpatient treatment.

I would appreciate your assessment and advice regarding this. I will be in touch to follow her progress.

Yours sincerely,

Doctor
TIME ALLOWED: READING TIME: 5 MINUTES Task 29
WRITING TIME: 40 MINUTES

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

20.3.97

Patient History
Derek Romano is a patient in your General Practice.
Subjective: 46 year old insurance clerk wants “check up” smokes 1 pkt cigarettes per day
high blood pressure in past
no regular exercise
father died aged 48 of acute myocardial infarction
married, one child
no medications or allergies
Objective: BP 150/100 P 80 regular
Overweight Ht – 170 cm Wt – 98 kg
Cardiovascular and respiratory examination normal
Urinalysis normal

Plan: Advise re weight loss, smoking cessation

Review BP in 1 month

8.4.97
Subjective: Still smoking, no increase in exercise

Objective: BP 155/100

Assessment: Hypertension

Plan: Commence nifedipine (calcium channel blocker) 20 mg daily

Check blood glucose, serum cholesterol
Cholesterol = 6.4 mmol/L
– WRITING SUBTEST
23.4.97
Subjective: Mild burning epigastric pain, radiating retrosternally. Occurs after eating and walking.

Objective: BP 155/100
Abdominal and cardiovascular exam otherwise normal.

Assessment: ? Gastric reflux. Non-compliance with anti-hypertensive medication.

Plan: Add Mylanta 30 mls q.i.d.

Increase nifedipine to 20 mg twice daily.

30.4.97
Subjective: Crushing retrosternal chest pain. Sweaty. Mild dyspnoea.
Onset while walking, present for about one hour.

Objective: BP 160/100 P 64 in obvious distress

Few crepitations at lung bases.
ECG – inferior acute myocardial infarction.

Assessment: Acute myocardial infarction

Plan: Oxygen given

Anginine given sublingually
Morphine 2.5 mg given IV stat
Maxolon 10 mg given IV stat
You decide to call an ambulance and send this man to the Emergency Department, at the Royal
Melbourne Hospital.

Writing Task:
Using the information in the case notes, write a letter of referral to the Registrar in the Emergency
Department of the Royal Melbourne Hospital, Flemington Road, Parkville, 3052.
In your answer:
● Expand the relevant case notes into complete sentences
● Do not use note form
● Use correct letter format

The body of your letter should be approximately 200 words. Use correct letter format.
Emergency Department
Royal Melbourne Hospital
Flemington Road
Parkville 3052

The Registrar 30 April, 1997

Dear Doctor,

Re: Mr Derek Romano

I am writing to refer Mr Romano, a patient of mine to you. Mr Romano, is 46 years old and is an
insurance clerk, he is married with one child, and is suffering from his first episode of ischaemic (or
cardiac) chest pain. The patient first attended me six months ago. His risk factors include:
hypertension, smoking (one packet per day), obesity, strong family history (father died of an acute
myocardial infarction aged 48) and hypercholesterolemia (Total cholesterol = 6.4 mmol). He has no
known allergies.

After persistently elevated blood pressure readings around 150/100, patient was commenced on
nifedipine and this was recently increased to 20 mg twice daily. He also uses Mylanta for reflux
oesophagitis. A cardiovascular examination on 23.4.97 was normal.

Today Mr Romano presented following a minimum of one hour of crushing, retrosternal chest pain.
He felt nauseated and sweaty with mild dyspnoea. Examination revealed a distressed and anxious
man with a pulse of 64 (sinus rhythm) and blood pressure of 160/100. Crepitations were noted on
chest auscultation. Electrocardiography revealed changes consistent with an inferior myocardial
infarction.

Oxygen was given and one anginine sublingually followed by morphine 2.5mg intravenously. His pain
has now settled but I consider he requires admission to the Coronary Care Unit for stabilisation. I will
telephone later to check on his condition.

Yours sincerely,

Dr X
TIME ALLOWED: READING TIME: 5 MINUTES Task 30
WRITING TIME: 40 MINUTES

Read the case notes below and complete the writing task which follows.
notes:
Today's Date: 15/03/10

Patient History
Mrs Karen Conway has consulted you, her GP, as she and her husband have been trying to conceive
for about 18 months without success, and she is becoming concerned that there may be something
wrong.
Karen is a 32 year old solicitor.
Her husband, William, is a 33 year old accountant.
Karen: previous pregnancy 10 years ago, terminated. William does not know about this.
William: no previous pregnancies.

15/02/10
Subjective
Karen attends on her own. She reports that neither she or William have any significant medical
problems. Neither partner smokes, although she reports that William drinks quite heavily. Also he
has to travel regularly with his job.
Married for 3 years, and decided to try for a pregnancy in May 2006, when Karen stopped the pill.
Was on Microgynon 30 for the previous 5 years.
Periods are regular
No history of gynaecological problems, or sexually transmitted diseases.

Objective
Karen overweight BMI 28.
Pulse and BP normal.
Abdo exam normal.
As is some time since she last had a smear test, you do a vaginal examination, which is normal, and
take a cervical smear.

Assessment
Although the couple have only been trying to conceive for 18 months, Karen is clearly very anxious,
and so you decide that further investigation is appropriate.
Plan
Blood tests for Karen required to confirm that her hormone levels are normal and that she is
ovulating. You explain to Karen that it is necessary for you to see her husband, William also, and ask
her to make an appointment for him. Karen anxious that you do not reveal her history of a
termination of pregnancy to him.

15/03/10
Karen re-attends, accompanied by her husband William Conway.

Subjective
Karen's baseline blood tests are normal, except the test for ovulation is borderline. However Karen
informs you that she has used a home ovulation-prediction test which did show positive, so it is
likely that she is ovulating. Smear test result negative.
As Karen reported, William has no significant medical problems. He says he only drinks 10 units per
week, which does not agree with Karen's previous comments that he drinks heavily. He also explains
that he works away from home approximately 2 weeks out of 4, so he is not so concerned that Karen
has not conceived yet, as he thinks that it is because they haven't been trying long enough.
Therefore not keen on being investigated.

Objective
William refuses to be examined as he doesn't think there is a problem.

Assessment
Karen is even more anxious that when first seen and wants to be referred to an infertility specialist,
whereas William is quite reluctant. She tells you that her sister has recently had IVF treatment.

Plan
You suggest that William do a semen analysis, to which he agrees reluctantly, under pressure from
Karen. You try to reassure Karen that it is not unusual to take up to 2 years to conceive, and there
are no obvious risk factors, however at Karen's insistence, you agree to refer them to a specialist,
while awaiting the results of the semen analysis. You give them some general advice regarding
timing of intercourse, and suggest to Karen that she should try to lose some weight. Lastly you check
that Karen is taking folic acid, 400 micrograms daily.
Writing Task:
You are her GP, Dr Claire Black. Write the referral letter to Dr John Expert MBBS FRANZCOG,
Gynaecologist and IVF Specialist, St Mary's Infertility Centre, Wickham Terrace, Brisbane.
In your answer:
● Expand the relevant case notes into complete sentences
● Do not use note form
● Use correct letter format

The body of your letter should be approximately 200 words. Use correct letter format.
Dr John Expert, MBBS, FRANZCOG
St Mary's Infertility Centre
Wickham Terrace
Brisbane

15.3.10

Dear Dr Expert,

Re: Karen Conway, DOB 1.2.78

William Conway, DOB 2.1.77

This couple have requested referral as they have been trying to conceive for approximately 18
months without success. I have tried to reassure them that there is no reason to be concerned yet,
particularly as William works away from home regularly and there are no risk factors in their history,
however Karen, particularly, was anxious to be referred sooner rather that later.

Karen has regular periods and has no history of gynaecological problems or sexually transmitted
diseases. Her hormone tests are all normal, and ovulation confirmed. I did a smear test on 15.2.08
which was negative, and examination then was normal. She is a little overweight, with a Body Mass
Index of 28, and I have advised that she lose some weight. Karen is taking folic acid 400 mcg daily.

William also has no significant medical problems and he declined examination. However, he has
agreed to do a semen analysis, but I don't as yet have the results. I will forward them on in due
course.

Thank you for seeing them and continuing with investigations as you think appropriate. I do wish
them success.

Yours sincerely,

Dr Claire Black (GP)

[184 words]
TIME ALLOWED: READING TIME: 5 MINUTES Task 31
WRITING TIME: 40 MINUTES

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

Patient History
John Haywood DOB 23.5.85. On holidays after overseas trip – staying with his parents in Brisbane for
several weeks before returning to Melbourne his normal residence. You are his parents regular GP.
He has experienced pains in his right calf since arriving from UK four days ago. States pain has
become increasingly severe and his calf is tender to touch.

07.01.08
Single, Monash University student studying commerce.
Smokes 8 – 10 cigarettes a day. Social drinker (4 – 6 small beers) mainly at the weekend.
Plays squash and walks regularly.
Currently not on any medication.
No known allergies

Objective
BP 120/70 P 74 regular
Cardiovascular and respiratory examination normal
Tenderness and swelling in right calf

Assessment
Suspected Deep Vein Thrombosis – Send to Queensland Xray for Ultra Sound.

Action
Schedule appointment for 8.1. 08 to review results
08.01.08
Results 4 cm thrombus in soleal vein 16 cm below knee crease in right calf.

Action
Explain diagnosis and treatment to John. Provide literature on “stop smoking’ initiatives. Prescribe
Clexane 40mg/0.4ml injections twice daily for three weeks. Arrange for nurse practitioner at your
clinic to teach John how to self inject. Advise John to avoid further flights for at least 4 – 6 weeks
depending on response to Clexane.

14. 01.08
Subjective
John comes to your surgery to report what he thinks is an allergic reaction to the injection.
Advises he has succeeded in reducing cigarettes to two a day.

Objective
BP 120/75 P 74 regular
Cardiovascular and respiratory examination normal
Red rash, bruising and welts around injection site.

Decision
Change prescription from Clexane to Fragmin 5000u/0.2ml injections twice daily. Prescribe soothing
cream for rash. Arrange appointment for Ultra Sound to monitor progress on 22.1 08

23.01.08
John comes to surgery for results of latest Ultra Sound. Advises he has not smoked at all since last
visit. He is keen to fly back to Melbourne in early February when his university course recommences.

Results
Persistent soleal thrombus - no significant change but evidence of small decrease in size

Objective
BP 130/70 P 72 regular
Decrease in tenderness and swelling in right calf.
Injection site improved but still some redness and irritation of the skin.
Assessment
Advised patient to cease Fragmin injections. To take ½ an aspirin daily. Flight to Melbourne in early
February OK Elastic stockings and exercise during flight recommended. Fragmin injection prescribed
to be given pre and post flight. Regular GP to be contacted before ceasing daily aspirin dosage.

Writing Task:
Write a letter to John’s regular GP - Dr. Sue Cairns, 291 Rae Street. Fitzroy North Melbourne 3068.
In your answer:
● Expand the relevant case notes into complete sentences
● Do not use note form
● Use correct letter format

The body of your letter should be approximately 200 words. Use correct letter format.
Dr. Sue Cairns
291 Rae Street
Fitzroy,
Victoria, 3068

23/01/2008

Dear Doctor Cairns,

Re: John Haywood

DOB 23/05/1985

Mr Haywood came and saw me because he has been experiencing pain in his right calf after his long
flight from Melbourne. He normally studies in Melbourne and was visiting his parents in the UK for a
couple of weeks. He smokes 8-10 cigarettes a day, is a social drinker and is not on any medication.

On examination today, his right calf was tender. I suspected a deep vein thrombosis which was
confirmed by ultrasound. The imaging showed a 4cm thrombis in the soleal vein 16 cm below the
knee extending into the right calf. I advised that he stop smoking and prescribed 40mg clexane twice
daily. Unfortunately he developed an allergy to this treatment one week later. I changed the
medication to fragmin 5000 IV twice daily and decided to review his condition with a new ultrasound
in two weeks.

Today the report showed that the thrombis has decreased in size. Furthermore the tenderness and
swelling has decreased. I put him on half an aspirin daily and recommended that he inject fragmin
before and after his flight back to Melbourne which he has planned in early February.

I advised him to contact you regarding further management of his condition.

Yours sincerely,

Dr X (GP)
TIME ALLOWED: READING TIME: 5 MINUTES Task 32
WRITING TIME: 40 MINUTES

Read the case notes below and complete the writing task which follows.
notes:
Patient History
Constance Maxwell is a patient in your General Practice
DOB 08.08.38 Married, 3 adult children

21.02.10
Subjective
Complains of inflamed, sticky and weeping eyes.
Thyroidism diagnosed Feb 07
High blood pressure June 09
Hip replacement July 09
Medications – Thyroxine 1mg daily, Atacand 4mg daily, Fosamax 10mg daily
No known allergies
Objective
BP 135 /75 P 74
Both eyes – red, watery discharge right eye worse than left
Assessment
Bilateral conjunctivitis –likely viral
Chlorsig Drops 4hrly

03.03.10
Subjective
No improvement to eyes, blurred vision

Objective
Odema eye lids ++
Marked conjunctival congestion

Plan
Chloramphenicol 0.5% sterile 1 drop 3 times daily
Bion Tears 1 drop each eye 4 hrly
Review 2 weeks
05.06.10

Subjective
Accompanied by husband. Very distressed. Has lost most sight in both eyes –can make out light or
dark shapes but unable to read or watch TV.

Objective
Marked odema upper and lower lids
White sticky discharge Unable to read eye chart

Plan
Refer immediately Emergency Dept, Royal Melbourne Eye Hospital.
Husband will drive to hospital

WRITING TASK

Using the information in the case notes, write a letter of referral to the Registrar, Emergency
Department, Royal Melbourne Eye Hospital, Alexandra Tce, Fitzroy, Melbourne 3051

In your answer:
● Expand the relevant case notes into complete sentences
● Do not use note form
● Use correct letter format

The body of your letter should be approximately 200 words. Use correct letter format.
The Emergency Department
Royal Melbourne Eye Hospital
Alexandra Parade
Fitzroy

05/06/10

Dear Doctor
Re. Mrs Constance Markwell

I am writing to refer Mrs Howell, a 72 year old married mother of 3 adult children who is presenting
with a visual impairment.

Initially, she presented to me on 21/2/10, complaining of inflamed, sticky and weeping eyes. Both
her eyes were reddish with watery discharge. However, her right eye was worse than the left eye.
Therefore she was prescribed chlorisig drops 4 hourly. She has had thyroidism for 3 years, high blood
pressure for 1 year and a hip replacement was done in 2009. Her current medications are Thyroxin 1
mg, Atacand 4 mg and Fosamax 10 mg daily. She has no known allergies.

On review after 2 weeks, she had made no improvement. In addition she had blurred vision with
odematous eye lids and conjunctival conjestion., so chloramphenicol was prescribed 0.5% one drop
three times daily and Bion tears one drop 4 hourly.

Unfortunately, today she was accompanied by her husband with complaints of impaired vision in
both eyes and an inability to read books or watch television. There was oedema in both eyelids with
white discharge. She could not read the eye chart.

In view of the above signs and symptoms I believe she needs immediate eye care facilities. I would
appreciate your urgent attention to her condition.

Yours sincerely

Dr X

[211 words]
TIME ALLOWED: READING TIME: 5 MINUTES Task 33
WRITING TIME: 40 MINUTES

Read the case notes below and complete the writing task which follows.
notes:
John Elvin is a 48-year-old patient in your General Practice
5/05/11
Subjective: Complaint of occasional mild central chest pain on exertion
Has mild asthma but otherwise previously well
Nil family history of cardiac disease
1 pack day smoker and drinks 10 standard drinks 5/7
Under significant stress with own business
Medications – seretide two puffs BD salbutamol two puffs prn
Allergies - Nil

Objective: Nil chest pain O/E

ECG NAD
Troponin level NAD

Assessment: Early stages of IHD

D/D - stress related chest pain
Alcohol dependence but not interested in changing

Plan: Check serum lipids

Refer for exercise stress test
Review in 1 week

12/5/11
Subjective: Still only very occasional chest pain on exertion
Has runny nose & pharyngitis at present with ↑asthma symptoms
Attended stress test with very mild chest pain at high exercise load

Objective: Some very slight ischaemic changes present in exercise test

Mild bilateral wheeze present
Cholesterol mildly ↑
Assessment: Ischaemic heart disease/angina
Viral upper respiratory tract infection

Plan: Commence on lipitor, nitrates(imdur), aspirin and prn anginine

Educate anginine use
Review in 2/52

26/5/11
Subjective: Chest pain for the last week
Still c/o frequent mild wheeze
Often forgets to take seretide puffers because of ETOH consumption

Objective Mild bilateral wheeze still present

Assessment Mild Asthma 2⁰ to ↓ compliance with medication

Alcohol dependence now affecting medication compliance

Plan Emphasised importance of preventative anti-asthma meds

Recommended pt write put a reminder for asthma and all medications on his fridge.
Encouraged pt to use prn salbutamol until asthma improves
Offered ETOH dependence treatment pharmacotherapy- will consider this.

1/6/11
Subjective: Passing by medical centre and c/o sudden onset crushing chest pain on background
of URTI and worsening asthma since last
Not relieved by anginine
Very audible wheeze

Examination ECG – mild ST elevation in anterior leads. ST 120

Lungs – O/A moderate wheeze and mild bilateral crackles. SP O2 86% on R/A
Heart – Slight S3 sound +ve

Assessment Likely anterior AMI; ? triggered by respiratory issues

Acute exacerbation of asthma 2⁰ to URTI
? Mild APO
Plan Paramedic transfer to ED
O2 15L via non-rebreather (pt isn’t CO2 retainer)
GTN patch applied
IV morphine 5mg given
Ipatropium Bromide 500ug given via nebuliser in view of tachycardia
Frusemide 40mg given

Writing Task:
Using information provided in the case notes, write a referral letter to Dr Jeremy Barnett, the
Emergency Registrar on duty at Maroubra Hospital, Lakes Rd, Maroubra.

In your answer:
● Expand the relevant case notes into complete sentences
● Do not use note form
● Use correct letter format

The body of your letter should be approximately 200 words. Use correct letter format.
Dr Jeremy Barnett
The Emergency Registar on Duty
Maroubra Hospital
Lakes Road
Maroubra

29/06/2018

Dear Dr Barnett,

Re: Mr John Elvin,

I am writing to refer Mr. Elvin, a 48-year-old businessman who is presenting with signs and symptoms
suggestive of anterior myocardial infarction and acute exacerbation of asthma. Your urgent treatment and
assessment would be greatly appreciated.

Mr Elvin presented to the general practice on 5/05/11 complaining of associated mild central chest pain on
exertion. He has a history of mild asthma for which he takes seretide and salbutamol inhalers. He smokes 1
pack daily and consumes about 10 drinks 5/7. In addition, he is under significant stress with his own
business. Please note, there are no family history and allergies.

On his subsequent visits, exercise stress test revealed very slight ischemic changes. Also, mild bilateral
wheeze was presented due to viral upper respiratory tract infection. He was commenced on Lipitor,
nitrates, aspirin and Anginine. I gave him some advice regarding improving his compliance with medications.

Today, Mr Elvin presented complaining of sudden onset of crushing chest pain and very audible
wheeze. Cardiovascular examinations showed mild ST elevation in anterior leads with ST 20 and slight S3
sound. Moreover, mild bilateral crackles were noted. GTN patch, IV morphine 5 mg, Ipatropium bromide
500 mg via nebulizer and Frusemide 40 mg were given.

In view of the above, my provisional diagnosis is acute myocardial infarction with exacerbation of asthma.
and have requested a paramedic transfer. If you have any queries, please do not hesitate to contact me.

Yours sincerely,

Doctor X

[241 words]
TIME ALLOWED: READING TIME: 5 MINUTES Task 34
WRITING TIME: 40 MINUTES

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

Yuxiang Meng is a 21 year old overseas student chef from China in your general practice. He only
speaks very basic English and sees you because you are a GP from a Chinese background and speak
Mandarin.

2.03.11
Chief complaint - URTI symptoms for 5 days.

O/E:
*Mild pharyngitis & rhinorrhea. T 37.5
*C/O chronic insomnia
*Observed to be elevated in mood, tangential & ? delusional about fixing the world’s nuclear waste
problem
*Nil obvious signs of organic syndromes

Assessment: Mild viral illness & ? mania/1st episode BPAD

Plan: Nil treatment for URTI, just rest & ↑fluid intake. Referral made to local community
mental health for urgent assessment. Pt. escorted home by his uncle. Diazepam 10mg
QID prescribed & to be given with community MH team’s supervision.
Investigations ( exclude organic pathology & baseline)
-FBC
-UEC
-TFTs
-LFTs
-CMP
-urgent CT scan
3.03.11
Mental health team used interpreter and concur with provisional diagnosis of mania.
They state the following: no immediate dangers to self/others; MH keen for GP involvement due to
language issues and they will monitor pt. daily; they are keen to avoid hospitalisation as pt.
very afraid of idea of psych. ward due to stigma of the same in China
Today pt’s uncle accompanied pt. to GP surgery get blood results.

O/E
* Bloods NAD except mildy ↓protein & mild hypokalaemia (3.2 K+)
*CT NAD
*MSE – still tangential and delusional about same theme, but only mildly elevated since sleeping
well post diazepam

Assessment: Likely non-organic mania

Plan:
*Commence pt. on quetiapine 50mg BD (starting dose)
*↓diazepam to 10mg either BD or TDS depending on MH team’s assessment.
*R/V in 3/7; likely ↑of quetiapine.
*Commence pt on K+ (Span K) tablets.

7.03.11
Pt. was relatively settled for 3/7 but uncle suspects he has secreted & discarded meds.
Last night stayed up all night singing Chinese revolutionary songs (not usual behaviour) and
running naked down his street. Uncle didn’t want to call MH for fear of ‘getting locked up’.

O/E
* Pt very elevated in mood, pressured in speech, loose in associations and fixated on having
to rid Australia of all nuclear waste by tomorrow.
Believes he can draw power from Mao Ze
Dong’s spirit to achieve this.
*Pt stripped naked in front of GP and tried to hug him.

Assessment Acute manic episode

Plan:
Offered stat quetiapine 100 mg & diazepam 20mg but refused.
Schedule pt under MHA
Have uncle accompany pt with ambulance & police to RNSH ED
Refer to on call psych reg Dr Ben Hinds
Update local MH team.
Long term – try to refer to Chinese speaking psychiatrist.

Writing Task:
Using information provided in the case notes, write a referral letter to Dr Ben Hinds, the Psychiatry
Registrar on duty at Maroubra Hospital, Lakes Rd, Maroubra.

In your answer:
● Expand the relevant case notes into complete sentences
● Do not use note form
● Use correct letter format

The body of your letter should be approximately 200 words. Use correct letter format.
Dr Ben Hinds
Psychiatry Register
Maroubra Hospital
Lakes Rd
Maroubra

7/3/2011

Dear Dr Hinds,
Re: Yuxiang Meng

I am writing to refer Mr Meng, a 21-year old student who is presenting with signs and symptoms
suggestive of an acute manic episode. It is important to note that he only speaks very basic English.

On 2/03/11, the patient initially presented with his first episode of mania complaining of chronic
insomnia where he was found to be elevated in mood and had tangential as well as delusions thoughts.
Therefore, he was referred to local community mental health, and diazepam 10 mg 4 times a day was
prescribed. In addition, routine investigations were ordered to exclude organic pathology.

A day later, Mr Meng was still tangential and delusional, but he was sleeping well with diazepam.
Investigation results were normal except mildly decreased protein and mild hypokalemia.
At that time, the diagnosis of mania was confirmed by mental health team. Accordingly, quentiapine
50 mg two times a day and Span K tablets were commenced, but diazepam was adjusted to 10 mg
either two or three times a day.

Today, the patient presented with worsening symptoms, was pressured in speech with abnormal
behavior and refused to take medications. Consequently, I have referred him to KNSH ED. Please note
that his uncle who accompanies him suspects non-compliance with medicines.

Based on the above, I believe that this patient needs a psychiatric consultation and would appreciate
your assessment and management of his condition. For further information, please feel free to contact
me.

Yours sincerely,

Doctor
[222 words]
TIME ALLOWED: READING TIME: 5 MINUTES Task 35
WRITING TIME: 40 MINUTES

Read the case notes below and complete the writing task which follows.
notes:
Mrs. Daniela STARKOVIC
45 years old, married 2 children
Past history
Migraines
Medications - nil

20/01/07
Subjective
presents with abdominal pain
doesn’t like fatty foods
otherwise well

10 days ago
- epigastric pain radiating to R side 1 hour after dinner
- associated nausea, no vomiting / regurgitation
- pain constant for 1 hour
- no medications
- no change bowel habits, no fever, no dysuria
Last night
- recurrence similar pain, worse
- duration 2 hours
- vomited X 1, no haematemesis
- pain constant, colicky features
- aspirin X 2 taken, no relief

Objective:
overweight
T 37° P 80 reg, BP 130/70
Medicine Letter 3mild tenderness R upper quadrant abdomen
no masses, no guarding, no rebound, bowel sounds normal
Murphy’s sign neg
Urine – trace bilirubin
Assessment: ?? biliary colic ?? peptic ulcer

Plan:
Liver Function Tests (LFTs)
Biliary ultrasound (US)
R/V 3/7

23/01/07

Subjective:
No further episodes
Patient anxious re possibility cancer

Objective:
LFTs – bilirubin 12 (normal range 6-30)
Alkaline phosphatase (ALP) 120 (normal < 115)
Aspartate transaminase (AST) 20 (normal 12-35)

Assessment: ? mild obstruction

US – small contracted gallbladder, multiple gallstones
Common bile duct diameter normal
Normal liver parenchyma

Assessment: cholelithiasis

Plan:
Reassurance re cancer
Referral Dr. Andrew McDonald (general surgeon) assessment, further
management, possible cholecystectomy
Writing Task:
Using the information in the case notes, write a letter of referral to Dr Andrew
McDonald a general surgeon at North Melbourne Private Hospital 86 Elm Road North
Melbourne 3051.

In your answer:
● Expand the relevant case notes into complete sentences
● Do not use note form
● Use correct letter format

The body of your letter should be approximately 200 words. Use correct letter format.
Dr Andrew McDonald
General Surgeon
North Melbourne Privet Hospital
86 Elm Road
North Melbourne

23/01/2007

Dear Doctor,

Re: Mrs. Daniel STARKOVIC

I am writing to refer this patient, a 45-year old lady who is presenting with signs and symptoms
suggestive of cholelithiasis.

On 20/01/07, Mrs. Starkovic first presented with abdominal pain. 10 days earlier, she had the first
episode of the epigastric pain radiating to the right side, which occurred one hour of her dinner and
was associated with nausea. This pain was constant and colicky in character and lasted for one hour.
However, in the previous night, she had worsening of symptoms with pain of 2 hours’ duration and
vomited once. On examination, mild tenderness over the right upper quadrant was noticed and
bilirubin was observed in her urine sample.
Therefore, LFTs and US were ordered and a review consultation was scheduled for 3 days later. It is
important to note that she is overweight.

Upon today’s review, US revealed a small contracted gallbladder as well as multiple gallstones, and
alkaline phosphatase was 120 but all the other findings were normal.

Based on the above, I would be grateful if you could assess and manage her condition with possible
cholecystectomy. For further information, please feel free to contact me.

Yours faithfully,

Doctor

[184 words]
TIME ALLOWED: READING TIME: 5 MINUTES Task 36
WRITING TIME: 40 MINUTES

Read the case notes below and complete the writing task which follows.
notes:
Patient History:
Name: Mr. Antonite Scott
Date of Birth: 18th March 1950
Height: 160cm
Weight: 74kg
Allergies: Shellfish
Substance Intake: Nil
Dentures: Nil

Social History:
Patient lives with his wife. All of their children live away. He is a smoker and an
alcoholic. He works as a bar tender.
Depression: controlled by medication
Family History:
Mother: History of Pneumonia
Father: Died of CVA (Cerebro Vascular Accident) recently.
Maternal Grandmother: Died of COPD
Maternal Grandfather: Unknown
Paternal Grandmother: Hypertensive
Paternal Grandfather: Known patient of depression

Past Medical History:

1990: Typhoid, followed by a jaundice attack
1996: HBsAg Positive
2006: Diagnosed with depression and kept on medicine to control it.

Present Symptoms:
Diabetic (blood sugar levels increasing continuously)
UTI (burning micturation and incontinence)
Cellulitis (swollen and painful legs)
Provisional Diagnosis: Type II diabetes mellitus

Plan: Refer to diabetologist/podiatrist for further treatment.

Writing Task:
Using the information in the case notes, write a letter of referral for further treatment to the
diabetologist/podiatrist, Dr. Britto, at City Hospital.

In your answer:
● Expand the relevant case notes into complete sentences
● Do not use note form
● Use correct letter format

The body of your letter should be approximately 200 words. Use correct letter format.
Dr. Britto
City Hospital
(Near to 154 Newcastle St)
Perth WA
Australia

(Today’s date)
Dear Dr. Britto,

Re: Mr. Antonite Scott, DOB 18th March 1950

Mr. Antonite Scott is being discharged from our hospital into your care today. He has been a
regular patient at our hospital for many years and has just been diagnosed as diabetic; there was
an increase in his blood pressure when the patient was admitted into our hospital recently.
The patient also complained of feeling a burning sensation while passing urine. The problem was
diagnosed by our team of doctors as a urinary tract infection (UTI), with burning micturation and
incontinence. The patient took several days to begin to recover, as the problem of the increase
in sugar was a continuous one.

The patient displayed problems with walking as well; his legs are swollen and he feels pain.
These symptoms can be attributed to the increase in blood sugar.

The patient has no significant medical history and none of his family members were diabetic. The
patient once suffered from typhoid followed by an attack of jaundice in 1990 and was also
diagnosed as HBsAg positive in 1996. He was also diagnosed with depression in 1996 and takes
medication to control this condition.

The patient was feeling well at the time of discharge but there is still a necessity to control his
blood sugar levels.
Please, contact me with any queries.
Yours sincerely,
Doctor
TIME ALLOWED: READING TIME: 5 MINUTES Task 37
WRITING TIME: 40 MINUTES

Read the case notes below and complete the writing task which follows.
notes:
Patient History:
Name: Mrs. Suzanne Mario
Date of Birth: 5th January, 1978.
Height: 158cm
Weight: 60kg
Allergies: dust, vinegar
Substance Intake: sleeping pills
Dentures: upper

Social History:
Patient lives alone, not married. She is a smoker and drinks occasionally
too. She works as an assistant manager for a non-profit organization.
Peptic ulcer: controlled by medication.

Family History:
Mother: history of cervical cancer
Father: died in an accident two years ago.
Maternal Grandmother: history of cancer
Maternal Grandfather: had LRTI twice
Paternal Grandmother: Unknown
Paternal Grandfather: died at the age of 92

Past Medical History:

2000: Irregular menstruation
2008: Removal of cyst from right breast

Present Symptoms:
Pain in the sides of both breasts
Can feel lumps
Provisional Diagnosis: breast cancer
Plan: refer to Oncologist for further examination and treatment.
Writing Task:
Using the information in the case notes, write a letter of referral for further treatment to the
Oncologist, Dr. Ansari, at Lake hospital, 14 Lake View Street, Card Well City.

In your answer:
 Expand the relevant notes into complete sentences
 Do not use note form
 Use letter format

The body of the letter should be approximately 180-200 words.

Dr. Ansari
Lake Hospital
14 Lake View Street
Card Well City

(Today’s date)

Dear Dr. Ansari,

Re: Mrs. Suzanne Mario, DOB 5th January 1978

Mrs. Suzanne Mario is being discharged from our hospital into your care today. She has been a
patient of cancer for several years now and has recently complained of intense pain in both of
her breasts; she could feel lumps in her breasts as well. She had a cyst removed from her right
breast in 2008 and the reports on the provisional diagnosis showed the possibility of breast
cancer.

There are two other cases of cancer in her family history: her mother had cervical cancer and her
maternal grandmother also had a cancer related problem, but we don’t have the full details
about this.

The patient has no medical history apart from the problems related to irregular menstruation,
noted in the year 2000. The patient takes sleeping pills and she smokes and drinks occasionally.
There is a necessity to tackle this problem as the patient is experiencing a lot of pain as well as
anxiety about the potential diagnosis. The patient lives alone and is not married.

Please, contact me with any queries.

Yours sincerely,

Doctor
TIME ALLOWED: READING TIME: 5 MINUTES Task 38
WRITING TIME: 40 MINUTES

Read the case notes below and complete the writing task which follows.
notes:
Patient History:
Name: Mr. Roberto Carlos
Date of Birth: 19th April 1948
Height: 164cm
Weight: 94kg
Allergies: iodine
Substance Intake: pain killers and sleeping pills
Dentures: upper and lower

Social History:
Patient is married and has two children. Children are settled away from parents.
They live alone. He is a chain smoker and a chronic alcoholic. He worked as a Professor before he
retired.
Tonsillitis: had tonsillectomy.

Family History:
Mother: was healthy, no medical problems.
Father: heart attack (died at the age of 88).
Maternal Grandmother: unknown.
Maternal Grandfather: unknown.
Paternal Grandmother: was a hypertensive patient.
Paternal Grandfather: had a history of varicose veins.

Past Medical History:

1990: Protrusion of veins and leg cramps.
Diagnosed as DVT and kept on treatment.
Started weight reduction treatment.
Present Symptoms:
Intolerance of leg cramps
Provisional Diagnosis: DVT

Plan: refer to a general surgeon for further treatment.

Writing Task:
Using the information in the case notes, write a letter of referral for further treatment to the
General Surgeon, Dr. Christo, at Wood Park Hospital, 18 Park street, Richmond City.

In your answer:
 Expand the relevant notes into complete sentences
 Do not use note form
 Use letter format

The body of the letter should be approximately 180-200 words.

Dr. Christo
Wood Park Hospital
18 Park Street
Richmond City

(Today’s date)

Dear Dr. Christo,

Re: Mr. Roberto Carlos, DOB 19th April 1948

Mr. Roberto Carlos is being discharged from our hospital into your care today. The patient is
suffering from intolerable leg cramps; on complaints of intense pain and cramps, the patient was
admitted into our hospital. Reports on the provisional diagnosis showed the possibility of DVT
(deep vein thrombosis).

Several years ago, the patient suffered from the same problem of cramping. Due to protrusion of
veins and leg cramps, the patient was diagnosed to have DVT in 1990 and a treatment plan was
suggested too – he began weight reduction treatment. Several years on, the patient is now
complaining of the same problem.

The patient is a chain smoker and he is alcoholic as well. Additionally, he sometimes uses pain
killers and sleeping pills as well; however, the names were not mentioned by the patient, nor the
purpose or reason for taking them.

The patient was well at the time of discharge from our hospital, apart from the problem related to
DVT.
Please, contact me with any queries.

Yours sincerely,

Doctor
TIME ALLOWED: READING TIME: 5 MINUTES Task 39
WRITING TIME: 40 MINUTES

Read the case notes below and complete the writing task which follows.
notes:
Patient History:
Name: Mrs. Agnes Rosario
Date of Birth: 5th September 1972
Height: 152cm
Weight: 56kg
Allergies: Nil
Substance Intake: pain killers
Dentures: Nil

Social History:
Patient is married and has no children. She works as an English Teacher for an
International School.

Family History:
Mother: history of PCOD
Father: history of asthmatic attack.
Maternal Grandmother: PCOD
Maternal Grandfather: unknown.
Paternal Grandmother: was diabetic
Paternal Grandfather: had a history of URTI
Past Medical History:
1998: irregular menstruation, acne. Had treatment for two months.
1999: menorrhagia for about 25 days.

Present Symptoms:
Menorrhagia and severe lower back abdominal pain
Provisional Diagnosis: PCOD
Plan: refer to gynecologist and obstetrician for further treatment.
Writing Task:
Using the information in the case notes, write a letter of referral for further treatment to the
Gynecologist and Obstetrician, Dr. Amanda, at Whitus Hospital, 112 Bill street, Emerald City.

In your answer:
 Expand the relevant notes into complete sentences
 Do not use note form
 Use letter format

The body of the letter should be approximately 180-200 words.

Dr. Amanda
Whitus Hospital
112 Bill Street
Emerald City

(Today’s Date)

Dear Dr. Amanda,

Re: Mrs. Agnes Rosario, DOB 5th September 1972

Mrs. Agnes Rosario is being discharged from our hospital into your care today. The patient is
suffering from severe menorrhagia and lower back abdominal pain. The reports on the provisional
diagnosis showed the possibility of polycystic ovary syndrome (PCOS) as well.

This is not the first time that the patient has been admitted into our hospital due to menorrhagia.
She also experienced the same problem of menorrhagia in 1999, treatment of which lasted for
about 25 days.

In the past, the patient has complained of irregular menstruation and acne and she underwent
treatment for this condition which lasted for about two months.

Her family history showed the presence of PCOS; her mother suffered from PCOS and her
maternal grandmother also showed signs of a PCOS related problem.

The patient was well at the time of discharge from our hospital, apart from the problem related
to menorrhagia or PCOS.

There is a need to take great care as the problem is severe this time and the patient is in a lot of
pain.

Please, contact me with any queries.

Yours sincerely,

Doctor
TIME ALLOWED: READING TIME: 5 MINUTES Task 40
WRITING TIME: 40 MINUTES

Read the case notes below and complete the writing task which follows.
notes:
Patient History:
Name: Mr. Stephen Brook
Date of Birth: 9th December 1987
Height: 168cm
Weight: 66kg
Allergies: barley
Dentures: Nil

Social History:
Patient is not married. He is a gym instructor for an international school.

Family History:
Mother: history of jaundice.
Father: history of peptic ulcer
Maternal Grandmother: was a healthy woman
Maternal Grandfather: CA prostate
Paternal Grandmother: had chickenpox during her childhood
Paternal Grandfather: had a history of UTI’s

Past Medical History:

2010: food poisoning and vomiting - had treatment.
2011: burning sensation and pain at xiphoid process and radiating to back, regurgitation,
vomiting. Had treatment but discontinued after six months – reasons unknown.

Present Symptoms:
Burning sensation and pain at xiphoid process and radiating to back during
mid night, vomiting.

Provisional Diagnosis: pancreatitis

Plan: refer to a general physician for further treatment.

Writing Task:
Using the information in the case notes, write a letter of referral for further treatment to the
General Physician, Dr. Mario, at City hospital, 15 River Street, Herberton City.

In your answer:
 Expand the relevant notes into complete sentences
 Do not use note form
 Use letter format

The body of the letter should be approximately 180-200 words.

Dr. Mario
City Hospital
15 River Street
Herberton City

(Today’s Date)

Dear Dr. Mario,

Re: Mr. Stephen Brook, DOB 9th December 1987

Mr. Stephen Brook is being discharged from our hospital into your care today. He was admitted
into our hospital due to a problem related to his pancreas and the reports on the provisional
diagnosis showed the presence of pancreatitis.

The patient was suffering from an intense pain and burning sensation at the xiphoid process.
There was an increase in this pain and burning sensation during the night time and the patient
also complained of vomiting.

Mr. Stephen Brook suffered from and was treated for food poisoning in 2010. He had faced a
similar kind of problem related to pancreatitis (the burning sensation and pain) earlier as well, in
2011. The treatment for this was not completed; it was discontinued after six months, but we
are unaware of the reasons why at this stage.

The patient was well at the time of discharge from our hospital, apart from the problem related
to pancreatitis.

There is a need to take great care as the problem is severe this time.

Please, contact me with any queries.

Yours sincerely,

Doctor
TIME ALLOWED: READING TIME: 5 MINUTES Task 41
WRITING TIME: 40 MINUTES

Read the case notes below and complete the writing task which follows.
notes:
Patient History:
Patient: Mary Reylon
DOB: 4th Sept 1963
Allergies: dust / penicillin

Social History: Professor at the university (teaches physics)

Lives with her husband (Winston Reylon)
Works for women rights organization
Family History:
 Mother – high BP, rheumatoid.
 Father – liver failure
 Maternal Grandmother- died of a heart attack (75)
 Maternal Grandfather – died of heart attack (81)
 Paternal Grandfather – a patient of high BP
 Paternal Grandmother – died at the age of 65 due to an accident

Past medical history:

 RSV illness (1965)
 Chicken pox (1973)
 Tonsils removed (1981)
 Miscarriage due to an accident (1987)
 Hyperthyroid (1989)

12 June 2009
Injury to the head (fell down the stairs)
Tourniquet applied (to stop the flow of blood)
Dizziness and queasiness
Large bump on the head
Patient complained of pain even after two days
Unable to sleep (for a week)
Took slipping pills three times (as suggested by the doctor), no effect
Other signs:
 Persistent or worsening headaches
 Imbalance
 Vomiting

Inference: Suggestive of intracranial hematoma

Plan: CT scan is the definitive tool for accurate diagnosis of an intracranial hemorrhage.

Writing Task:
Using the information in the case notes, write a letter of referral for further investigation and
definitive diagnosis to the neurologist, Dr. Wilson, at London Bridge Hospital, 27 Tooley St
London, Greater London.

In your answer:
 Expand the relevant notes into complete sentences
 Do not use note form
 Use letter format

The body of the letter should be approximately 180-200 words.

Dr. Wilson
London Bridge Hospital
27 Tooley St London
Greater London

(Today’s date)

Dear Dr. Wilson,

Re: Mrs. Mary Reylon, DOB 4th Sept 1963

Mrs. Mary Reylon is a patient, who was admitted into our hospital on the 12thof June 2009.

Mrs. Mary Reylon fell from the staircase and suffered an injury to her head. As she was profusely
bleeding, a tourniquet was also applied around her head, to stop the flow of blood. The patient
began to feel dizziness and queasiness after that and a large bump on her head developed too.
The patient began to complain of pain even though pain killers were given.

The patient has not been able to sleep for about a week now; the patient even tried sleeping pills
to get enough sleep but the sleeping pills have proven to be ineffective for her. The patient has
also complained of persistent headaches, imbalance and vomiting, which are all suggestive of
intracranial hematoma. The CT scan is the definitive tool for accurate diagnosis of intracranial
hemorrhage. Hence, it is requested that the scan is taken so that proper action can be taken.

Please, contact me with any queries or if you would like to know more about the patient.

Yours sincerely,

Doctor
TIME ALLOWED: READING TIME: 5 MINUTES Task 42
WRITING TIME: 40 MINUTES

Read the case notes below and complete the writing task which follows.
notes:
Patient History:
Patient: Nicole Katie
DOB: 12 July, 1971
Social History:
Lives with her husband (Ivan) and their daughter (Lydia Imogen)
House wife (left work after she was married)
Family history: No family history
But mother died of kidney failure
Past medical history:
Suffered severe attack of TB (1983)
Appendices (1987)
Depression (due to the sudden death of the first baby – 1992)
Allergic reactions (uterine infection - 1997)

15 April 2005
Failure in digestion
Unable to eat properly due to pain in the stomach
Took pain relievers, analgesics (for two continuous days)
Problem worsened
Felt pain, radiating back to the lower abdomen
Change in coloration of urine (yellowish)
Loss of appetite
Weight loss – 2.5 kg within 15 days
Vomited twice

18 April, 2005
Other signs:
Severe pain, lasted for several hours
Pain and vomiting, shortness of breath
Blood in bowel motions and urine
High fever and sweats

Plan: Abdominal CT scan suggested for accurate diagnosis of abdominal pain.

Writing Task:
Using the information in the case notes, write a letter of referral for further investigation
and a definitive diagnosis to Dr. Ralph Emerson, at Royal London Hospital, Whitechapel Rd,
Greater London E1 1BB, United Kingdom.

In your answer:
 Expand the relevant notes into complete sentences
 Do not use note form
 Use letter format

The body of the letter should be approximately 180-200 words.

Dr. Ralph Emerson
Royal London Hospital
Whitechapel Rd
Greater London E1 1BB
United Kingdom

(Today’s date)

Dear Dr. Ralph Emerson,

Re: Mrs. Nicole Katie, DOB 12 July 1971

Mrs. Nicole Katie is a patient, who was admitted into our hospital on the 15th of April 2005.
Nicole Katie was suffering from some kind of digestion problem, which was undetected.

The patient was not able to eat properly and was feeling a lot of pain in her stomach. The
patient took some pain relievers (names are mentioned in the attached report) which, in fact,
worsened the problem. The patient began to feel pain which radiated back to her abdomen and
also noted a change in the color of her urine. The patient had lost her appetite, causing her to
lose almost 2.5 Kg within the course of 15 days.

During her stay at our hospital from April 15 to April 18, the condition of the patient continued
deteriorating; especially on the 18th of April, when the patient complained of much more severe
pain which lasted for hours. She experienced pain, shortness of breath and vomiting. Blood in
her bowel motion and urine was also noted. The patient has had a high fever and has been
suffering from severe sweating.

Hence, it is requested that the abdominal CT scan should be taken for an accurate diagnosis of
the abdominal pain, as a matter of urgency.

Please, contact me with any queries.

Yours sincerely,

Doctor
TIME ALLOWED: READING TIME: 5 MINUTES Task 43
WRITING TIME: 40 MINUTES

Read the case notes below and complete the writing task which follows.
notes:
Patient History:
Mark Henry is 53-year-old patient at your General Practice. Just recently, he complained of acute
onset of double vision and right eyelid droopiness.
Social History:
The patient lives with his wife
Works as a car mechanic
Denies use of illicit drugs or tobacco
Rarely drinks
Family History:
His mother suffered from migraines (died at the age of 83 due to heart attack)
His paternal father had a stroke at the age of 67
No other family history of strokes or vascular diseases

9/07/2009
Was sitting in his room; felt sensation in eye lids
Noticed blurred vision
Appearance of double vision (with objects appearing side by side)
Pain in both the eyes
Transferred to the hospital by his son
Intermittent pounding bifrontal headache
Rated the pain as 7 or 8 on a scale of 1 to 10

General physical examination:

The patient is significantly overweight.
Temperature is 37.6.
Blood pressure is 130/60.
Pulse is 85.
There is no tenderness over the scalp or neck and no bruits over the eyes or on the neck.
No proptosis, lid swelling, conjunctival injection, or chemosis.
Cardiac exam shows a regular rate and no murmur.

Past Medical History:

1) Migraine headaches, as described in HPI.
2) Depression.
There is no history of diabetes or hypertension.

Allergies: None.

Medications: Zoloft 50 mg daily, ibuprofen 600 mg a few times per week, and vicodin a few
times per week.

Other necessary information

He denies associated vomiting, nausea, numbness, weakness, photophobia, loss of vision, seeing
flashing lights or zigzag lines etc.
His recent headaches differ from his “typical migraines” (occurred 4 -5 in his entire life time).
He has never taken anything for these headaches (other than ibuprofen or vicodin).

Writing Task:
Using the information in the case notes, write a letter of referral for further investigation and a
definitive diagnosis to Dr. Martin, at National Hospital for Neurology, 33 Queen Square,
London WC1N 3BG, United Kingdom.

In your answer:
 Expand the relevant notes into complete sentences
 Do not use note form
 Use letter format

The body of the letter should be approximately 180-200 words.

Dr. Martin
National Hospital for Neurology
33 Queen Square London WC1N 3BG
United Kingdom
(Today’s date)
Dear Dr. Martin,
Re: Mr. Mark Henry, acute onset of double vision and right eyelid droopiness.
Mr. Mark Henry is a patient, who was admitted into our hospital on 9 / 7 / 2009 with complaints
of acute onset of double vision and right eyelid droopiness.

On 9 / 7 / 2009, the patient was sitting in his room when he felt a strange sensation in his
eyelids; he began to feel pain in his eyes as well. He also complained of the sudden appearance
of double vision and an intermittent pounding bifrontal headache.

Reports on the general examination were clear: his pulse was 85 and BP 130 / 60; there was no
swelling of the lids or proptosis.

His medical history shows that he has suffered from migraines (headaches) and depression.
The patient was prescribed Zoloft (50 mg - daily) and ibuprofen (600 mg - a few times per week).

The patient denied associated vomiting, nausea, numbness or weakness or loss of vision etc. but
said that his recent headaches differ from his typical migraines, which actually only occurred 4-5
times in his whole life time. The patient has never taken anything for the headaches, except
ibuprofen or vicodin.

As the problem presented by the patient is a complex one, further investigation and a definitive
diagnosis is required.

Please, contact me with any queries.

Yours sincerely,

Doctor
TIME ALLOWED: READING TIME: 5 MINUTES Task 44
WRITING TIME: 40 MINUTES

Read the case notes below and complete the writing task which follows.
notes:
Patient History:
Joseph Malcolm is a patient at your General Practice. Just recently, he started complaining of
occasional breathlessness and difficulty in breathing.
Age: 42
Gender: male
Occupation: office manager
Subjective Patient Complaints:
Adult onset asthma- dyspnea, cough
Occasional wheezing symptoms upon increased exercise or when under stress.

Prior contributory health history:

1) Seasonal upper respiratory allergies
2) Occasional loose stools when under stress
3) Occasional episodes of mild eczema (dermatitis)
4) Reports a history of being healthy, aside from this recent asthma problem

What provokes the symptoms?

Provoked by exercise, emotional/physical stress
Cigarette smoke
Seasonal respiratory allergies

Site of symptomatology:
Bronchial, lung, chest/thoracic region
Time of day/duration of symptoms:
Daily episodes of dyspnea
Symptoms often worsen at 3-5 AM (coughing increases)

Medications:
Symptoms temporarily eased with prescription (bronchial inhaler medication).
Writing Task:
Using the information in the case notes, write a letter of referral for further investigation and a
definitive diagnosis to Dr. Robert Frances, at St. George’s Hospital, Black Shaw Road, London
SW17 0QT, United Kingdom.

In your answer:
 Expand the relevant notes into complete sentences
 Do not use note form
 Use letter format

The body of the letter should be approximately 180-200 words.

Dr. Robert Frances
St. George’s Hospital
Black Shaw Road
London SW17 0QT
United Kingdom

(Today’s date)

Dear Dr. Robert Frances,

Re: Mr. Joseph Malcolm, age 42

Mr. Joseph Malcolm is a patient at our hospital who visits regularly. Just recently, he complained
of occasional breathlessness and difficulty in breathing. The patient’s health history shows
seasonal upper respiratory allergies and occasional episodes of mild eczema.
The patient is reported to be healthy, apart from this recent asthma related problem.

This problem related to asthma, or breathlessness, in the words of the patient, increases with
exercise, emotional or physical stress and cigarette smoking.

The patient has been experiencing problems related to dyspnea for many days (dates are not
mentioned). The symptoms often get worse in between 3-5 am; the patient coughs a lot and he
is not able to have full control over his daily activities.

Sometimes, the above symptoms temporarily go away when the patient uses bronchial inhaler
medication; but when the patient doesn’t pay attention to medication or gets involved in any
kind of physical activity, then the same problem of difficulty in breathing occurs.

Further investigation and a definitive diagnosis is vital here as the patient has not been feeling
well for quite a while now.

Please, contact me with any queries.

Yours sincerely,

Doctor
TIME ALLOWED: READING TIME: 5 MINUTES Task 45
WRITING TIME: 40 MINUTES

Read the case notes below and complete the writing task which follows.
notes:
Patient History:
Mr. Marques is a patient at your general practice who has recently complained of abdominal pain.
Name of the patient: Mr. Marques , Age: 65
October 7, 2006
Chief complaint: abdominal pain
 Complained of a sharp, epigastric abdominal pain (gradually worsening over the past 1-2 months).
 Pain is located in the epigastric region and left upper quadrant of the abdomen.
 Doesn’t radiate.
 The pain is relatively constant throughout the day and night (but does vary in severity).
 Rated the pain as 6/10 at its worst.
 He has not tried taking any medicines to relieve the pain.
 The pain is not associated with food or eating (but occasional heartburn).
 Denies any abdominal trauma or injury.
 Complained of weight loss (5lb weight loss over the past 1-2 months).
 The patient has experienced some nausea with the abdominal pain but has not vomited.

Family History:
Father died due to a heart attack.
Mother’s medical history is not known.
No known family history of colon cancer.

Social History:
The patient is a retired lecturer.
He lives with his wife and two grandchildren.
He denies past or present tobacco and illicit drug use.
He denies alcohol use.

Past Medical History: other active problems

High blood pressure, diagnosed two years ago, but well-controlled now.
Depression poorly controlled; started prozac 2 months ago, but still feels depressed.
Hospitalizations: MI, 2003.

Surgeries/procedures: Cardiac catheterization, post-MI, 2003.

Medications:
Aspirin 81mg po qd, since his MI 3 years ago
Metoprolol 100mg po qd, for two years
Prozac 20mg po qd, started 2 months ago
Allergies: No known drug allergies.
No food or insect allergies.

Other information
Pulmonary – denies shortness of breath, denies cough.
Cardiovascular – denies chest pain, denies palpitations.
Genitourinary – denies dysuria, denies increased frequency or urgency of urination.

Writing Task:
Using the information in the case notes, write a letter of referral for further investigation and a
definitive diagnosis to Dr. Ivan Gonz, at Willington Hospital, Central Building, 21 Wellington
Road, St John's Wood London.

In your answer:
 Expand the relevant notes into complete sentences
 Do not use note form
 Use letter format

The body of the letter should be approximately 180-200 words.

Dr. Ivan Gonz
Willington Hospital
Central Building
21 Wellington Road
St John's Wood London
(Today’s date)
Dear Dr. Ivan Gonz,

Re: Mr. Marques, age 65

Mr. Marques has been a patient with us for several months now. Just recently, he complained of
severe abdominal pain; the patient complained of a sharp, epigastric abdominal pain which he
says has increased over the last two months.

The pain is located in the epigastic region and left upper quadrant of the abdomen. This pain is
relatively constant throughout the day, but may sometimes vary in severity. The patient has
rated this pain as 6 on a scale of 1-10 and hasn’t taken anything to relieve the pain. He has
denied any abdominal trauma or injury.

The patient’s medical history includes the fact that he has been a BP patient for over two years;
his blood pressure is now well controlled. In addition, he has been suffering from depression
related problems too; he started taking prozac two months ago, but he still feels depressed. The
patient is reported to have no drug allergies or food or insect allergies.
Mr. Marques was once hospitalized for myocardial infarction, in 2003, and he has been on
medications regularly since then. Presently, the patient is taking aspirin - 81mg po qd, and has
been since his MI, 3 years ago; and metoprolol 100 mg po qd, which he has been taking for the
past two years.

There is a need for further investigation and a definitive diagnosis.

Please, contact me with any queries.

Yours sincerely,
Doctor
TIME ALLOWED: READING TIME: 5 MINUTES Task 46
WRITING TIME: 40 MINUTES

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

Patient History:
Name: Jennet Berritto
Date of Birth: 22 April, 1971
Height: 163 cm
Weight: 75kg
Allergies: Nil

Social History:
Lives with her husband
Likes gardening
Doesn’t drink / smoke
Sometimes takes betel leaves
Family History: None to report

Medical History
Type 2 diabetes mellitus (2/10/2001)
Hypertension (5/4/2006)
Stomach ulcers (12/7/2007)
Ankle injury (22/5/2008)
COPD (27/6/2011)

Present Symptoms:
Intense coughing
Pain in the chest, shoulder and back
Shortness of breath
Change in voice
Harsh sounds with each breath
Change in color and volume of sputum
Diagnosis
Chest X-ray - not cleared
CT-Scan - positive
Stage 2A (lung cancer)
The tumor is 5.5 cm
Cancer cells spread across lymph nodes

Plan: Refer to Dr. Bryan Hardy for further treatment

Writing Task:
Using the information in the case notes, write a letter of referral for further treatment to
Pulmonologist, Dr Bryan Hardy, at EMR Hospital,v25 Rocklands Rd North Sydney NSW,
Australia, outlining the details of the patient.

In your answer:
 Expand the relevant notes into complete sentences
 Do not use note form
 Use letter format

The body of the letter should be approximately 180-200 words.

Dr. Bryan Hardy
EMR Hospital
25 Rocklands Rd
North Sydney NSW
Australia

(Today’s date)

Dear Dr. Bryan Hardy,

Sub: Jennet Berritto, DOB 22 April 1971

Jennet Berritto is an elderly woman who visited our hospital due to complaints of intense
coughing, shortness of breath, change in her voice etc. She was feeling pain in the chest and pain
around her shoulder as well. This pain was accompanied by back pain as well and she was aware
of a harsh sound with each breath. The patient complained of a change in color and volume of
sputum too.

Her medical history reveals that she has been a patient of diabetes for over 14 years now. She has
also been a patient of hypertension (5/4/2006) and has problems related to COPD (27/6/2011).

X-rays taken were not clear so a CT scan was suggested. The reports on the CT were positive; the
diagnosis showed that she has lung cancer - stage 2A). The tumor seemed to be growing and
presently measures at 5.5 cm. Cancer cells are spreading across the lymph nodes.

The patient doesn’t drink or smoke but she is habituated to taking betel leaves.

The condition of the patient at the time of discharge was as good as can be expected.

I would like to request for you to look into this case and provide a suitable treatment. Please, do
let me know if you would like any further details about the patient.

Yours sincerely,

Doctor Adams
TIME ALLOWED: READING TIME: 5 MINUTES Task 47
WRITING TIME: 40 MINUTES

Read the case notes below and complete the writing task which follows.
notes:
Patient History:
Name: Christian Aula
Date of Birth: 12/9/1975
Height: 159 cm
Weight: 69 kg
Allergies: Nil

Social History:
Lives with her daughter and son-in-law
Enjoys walking
Doesn’t drink / smoke
Family History:
Mother - died of heart attack (had a TIA stroke as well)
Father - died of liver failure
Medical History:
Allergic rhinitis
History of advanced, home oxygen (02) - dependent COPD and heart failure
Benign essential hypertension
Chronic respiratory failure

Present Medications
Prednisone 5 mg qd, montelukast 10 mg every evening, albuterol-ipratropium MDI 2 puffs q4h prn
SOB, carvedilol 3.125 mg bid, bumetanide 2 mg bid, fluticasonesalmeterol 500-50 mcg/dose disk
with device 2 puffs bid, potassium chloride 20 mEq tablet ER bid, tiotropium bromide 18-mcq
capsule one inhalation every morning, albuterol/ipratropium hand-held nebulizer q4h prn SOB.
Present Symptoms:
Weakness, numbness or paralysis in the face (left side) Slurred or garbled speech / difficulty in
understanding others
Double vision
Dizziness
Loss of balance or coordination
Diagnosis
TIA (Transient Ischemic Attack) Confirmed
BP Checked: 150/95 millimeters of mercury (mm Hg)

Plan: Refer to Dr. Sally Anderson for further treatment

Writing Task:
Using the information in the case notes, write a letter of referral for further treatment to the
Hypertension Specialist, Dr. Sally Anderson, at Community Hospital, 33 Albany St Crows Nest
NSW, Australia, outlining the details of the patient.

In your answer:
 Expand the relevant notes into complete sentences
 Do not use note form
 Use letter format

The body of the letter should be approximately 180-200 words.

Dr. Sally Anderson
Hypertension Specialist
Community Hospital
33 Albany St Crows Nest NSW
Australia
(Today’s date)

Dear Dr. Sally Anderson

Sub: Christian Aula, DOB 12/9/1975

Christian Aula is an elderly woman who was admitted to our hospital due to weakness,
numbness or paralysis on the left side of her face. The patient was not able to speak properly
(garbled speech) and was displaying difficulty in understanding people around her. She
complained of double vision, dizziness and loss of balance and coordination as well.

The diagnosis confirmed the presence of TIA - transient ischemic attack. Her BP was checked at
the time of admission and was recorded as 150/95 millimeters of mercury (mm Hg).

Her medical history reveals that she has allergic rhinitis, has problems related to COPD and
benign essential hypertension. The list of her medications include the following: prednisone 5
mg qd, montelukast 10 mg every evening; albuterolipratropium MDI 2 puffs q4h prn SOB;
carvedilol 3.125 mg bid; bumetanide 2 mg bid; fluticasone-salmeterol 500-50 mcg/dose disk with
device 2 puffs bid;
potassium chloride 20 mEq tablet ER bid; tiotropium bromide 18-mcq capsule one
inhalation every morning; albuterol/ipratropium hand-held nebulizer q4h prn SOB.

The condition of the patient at the time of discharge was good, aside from the symptoms listed above.

I would like to request that you look into this case and provide suitable treatment.
Please, do let me know if you require any further information about the patient.

Yours sincerely,

Doctor
TIME ALLOWED: READING TIME: 5 MINUTES Task 48
WRITING TIME: 40 MINUTES

Read the case notes below and complete the writing task which follows.
notes:
Patient History:
Name: Huang Bowra
Date of Birth: 27/7/1981
Height: 168 cm
Weight: 79 kg
Allergies: sulfa drugs / tetracyclines

Social History:
Lives alone
Drinks a lot
Smokes 2ppd of cigarettes daily
Family History:
No family history
Medical History:
Anxiety, depression (1999 - due to sudden death of his mother)

Medicine Writing Tests 11 – 15 with

Sample Answers
Obesity (2000)
Urinary incontinence (2003)
Hypertension (2007)
Insomnia (2009)

Present Medications
Norvasc 5 mg daily for hypertension
Lorazepam 1 mg HS for insomnia
Vistaril 25 mg BID PRN for anxiety (only when required)
Celexa 10 mg daily for depression (only when required)
Present Symptoms:
Indigestion
Dull, burning pain in the stomach
Burning sensation in the chest
Pain elevates after eating, drinking or taking antacids
Weight loss (has lost about 5 kgs in the course of 15-20 days)
Loss of appetite
Not wanting to eat because of pain
Nausea
Vomiting
Burping
Bloating

Diagnosis
Endoscopy confirmed the presence of stomach ulcers
Ulcers - one half inch in diameter

Plan: Refer to Dr. Mathew Corrado for further treatment.

Writing Task:
Using the information in the case notes, write a letter of referral for further treatment to Dr.
Mathew Corrado, at Flivo Hospital, 9 Mount Street Hunters Hill NSW, Australia, outlining the
details of the patient.

In your answer:
 Expand the relevant notes into complete sentences
 Do not use note form
 Use letter format

The body of the letter should be approximately 180-200 words.

Dr. Mathew Corrado
Flivo Hospital
9 Mount Street
Hunters Hill NSW
Australia
(Today’s date)
Dear Dr. Mathew Corrado,

Sub: Huang Bowra, DOB 27/7/1981

Huang Bowra is an elderly man who visited our hospital with complaints of symptoms which
were related to stomach ulcers. The patient complained of indigestion, a dull, burning pain in his
stomach and a burning sensation in his chest.
The pain elevated when he was eating or drinking and when he took antacids.

The patient had also lost about 5 Kgs within the course of 15-20 days, probably resulting from his
loss of appetite; it was painful for the patient to eat. He also complained of nausea, vomiting,
burping and bloating and he was quite distressed upon admission to hospital.
An endoscopy confirmed the presence of stomach ulcers which are one half inch in diameter.
Therefore, a course of treatment needs to be put into place.
The patient’s medical history shows that he has had problems related to obesity and urinary
incontinence. He is currently taking medicine for hypertension, insomnia, anxiety and
depression.
The list of present medications includes the following: norvasc 5 mg daily for hypertension;
lorazepam 1 mg HS for insomnia; vistaril 25 mg BID PRN for anxiety (only when required); and
celexa 10 mg daily for depression (only when required).

The condition of the patient at the time of discharge was good, but his stomach ulcers need so
be treated as a matter of urgency.

I would like to request for you to look into this case and provide suitable treatment.
Please, do let me know if you require any further information about the patient.
Yours sincerely,

Doctor
TIME ALLOWED: READING TIME: 5 MINUTES Task 49
WRITING TIME: 40 MINUTES

Read the case notes below and complete the writing task which follows.
notes:
Patient History:
Name: Abora Qualin
Date of Birth: 7/8/1979
Height: 179cm
Weight: 81 kg
Allergies: sulfa drugs
Social History:
Lives with her son
Drinks a lot
Quit smoking three months ago
Family History:
Data not available
Past Medical History
Hypertension (2001)
Urinary tract infection (2003)
Type 2 diabetes mellitus (2007)
Dyslipidemia (1 year ago)
Constipation (1 year ago)
Vital Signs
BP: 124/76, P: 89, RR: 18, T: 37.2°C
List of Medications
Lantus 10 units QHS, lisinopril 10 mg, glipizide XL 7.5 mg, ASA 81 mg,
hydrochlorothiazide 12.5 mg, simvastatin 80 mg, docusate 100 mg PRN.
Present Symptoms:
Complaining of severe back pain / groin pain
Vomiting
Fever
Chills
Nausea
Painful urination
Diagnosis
Urine sample - positive (presence of white blood cells in abundance)
Ultrasound - obstructions in the urinary tract

Result: UTI confirmed

Plan: Refer to Dr. Katherine Mathel for further analysis and treatment.

Writing Task:
Using the information in the case notes, write a letter of referral for further treatment to Dr.
Katherine Mathel, at Marino Kidney Center, 3/77 South Terrace Como WA, Australia, outlining
the details of the patient.

In your answer:
 Expand the relevant notes into complete sentences
 Do not use note form
 Use letter format

The body of the letter should be approximately 180-200 words.

Dr. Katherine Mathel
Marino Kidney Center
3/77 South Terrace Como WA
Australia

(Today’s date)

Dear Dr. Katherine Mathel,

Sub: Abora Qualin, DOB: 7/8/1979

Abora Qualin is an elderly woman who visited our hospital with complaints of symptoms which
were related to a UTI. Upon admission, the patient complained of severe back pain and groin
pain, vomiting and nausea. The patient was also suffering from a fever and was feeling pain
whilst passing urine. Consequently, a urine test was done which confirmed the presence of a
urinary tract infection.

The patient’s medical history shows that she had this urinary tract infection at an earlier date as
well; she first experienced this problem in the year 2003. For the last year, she has been
suffering from problems related to dyslipidemia and constipation as well. She has high BP, which
was diagnosed in the year 2001, and high blood sugar levels as well, diagnosed in the year 2007.

The medications which she is taking at the moment include the following: lantus 10 units QHS;
lisinopril 10 mg; glipizide XL 7.5 mg; ASA 81 mg; hydrochlorothiazide 12.5 mg; simvastatin 80 mg;
and docusate 100 mg PRN.

The patient is reported to be allergic to sulfa drugs.

The condition of the patient at the time of discharge was good, aside from the symptoms related
to the UTI.

I would like to request for you to look into this case and provide suitable treatment.
Please, do let me know if you require any further details about the patient.

Yours sincerely,

Doctor Lewis
TIME ALLOWED: READING TIME: 5 MINUTES Task 50
WRITING TIME: 40 MINUTES

Read the case notes below and complete the writing task which follows.
notes:
Patient History:
Name: Marcello Caprige
Date of Birth: 12/2/1979
Height: 168 cm
Weight: 73 kg
Allergies: Nil

Social History:
Married / Lives with his wife and son
Doesn’t drink
Smokes
Chews tobacco
Family History: no family history

Past Medical History

Hypertension
Type 2 diabetes mellitus
Depression
Osteoarthritis
Hyperlipoproteinemia

List of Medications
Metformin 1,000 mg PO BID, atorvastatin 20 mg PO QHS, lisinopril 20 mg PO QD,
furosemide 20 mg PO QD, aspirin 81 mg PO QD, glimepiride 2 mg PO QAM, venlafaxine
75 mg PO TID, fish oil 1,200 mg PO QD.

Present Medical Condition:

Change in blood pressure (last recorded 150/100)
Present Symptoms
Shortness of breath
Severe headaches
Severe anxiety
Nose bleeding (occurred twice in the last three days)

Diagnosis
High blood pressure noted (170/110)
Result: Hypertension (Stage 2)
Plan: Refer to Dr. Avelin Cooper for further analysis and treatment.

Writing Task:
Using the information in the case notes, write a letter of referral for further treatment to Dr.
Avelin Cooper, at MKZ Hospital, 697 Beaufort St Mt Lawley WA, Australia, outlining the details
of the patient.

In your answer:
 Expand the relevant notes into complete sentences
 Do not use note form
 Use letter format

The body of the letter should be approximately 180-200 words.

Dr. Avelin Cooper
MKZ Hospital
697 Beaufort St
Mt Lawley WA
Australia
(Today’s date)
Dear Dr. Avelin Cooper,
Sub: Marcello Caprige, change in blood pressure (last recorded 150/100)

Marcello Caprige is an elderly man who was admitted into our hospital due to a significant
change in his blood pressure. The patient was not able to breath properly and was experiencing
a shortness of breath. In addition, he was suffering from severe headaches and anxiety. The
patient also complained of nose bleeding, which has occurred twice in the last three days.

After thorough testing, the diagnosis revealed that the patient was at hypertension stage 2. His
blood pressure, which was noted at that time, was very high (170/110).
His medical history shows that he has diabetes as well (type 2 diabetes mellitus) and that he has
been suffering from depression, osteoarthritis and hyperlipoproteinemia as well.

The list of the medications which the patient is taking at present include the following:
metformin 1,000 mg PO BID; atorvastatin 20 mg PO QHS; lisinopril 20 mg PO QD; furosemide 20
mg PO QD; aspirin 81 mg PO QD; glimepiride 2 mg PO QAM; venlafaxine 75 mg PO TID; and fish
oil 1,200 mg PO QD.

The patient does not drink alcohol but he does smoke and chew tobacco.
The condition of the patient at the time of discharge was good, apart from his symptoms related
to high blood pressure.
I would like to request that you look into this case and provide suitable treatment.
Please, don’t hesitate to contact me if you require any further information about the patient.
Yours sincerely,

Doctor
Writing Recall
Writing Recall 2014

1 /2014 = Write a letter of referral to Admitting officer at the Emergency Department,

Children's Hospital for further assessment of infant who has constipation and dehydration.

2 /2014 = Write a letter of referral to: Colorectal surgeon for urgent assessment of a
man who has colon adenocarcinoma.

3 /2014 = Write a letter of referral to: Endocrinologist for further assessment of a

woman who has POCS.

5 /2014 = Write a letter of referral to: Rheumatologist for further treatment and
investigations of a man who has gout arthritis.

6 /2014 = Write a letter of referral to: Endocrinologist for further assessment and
management of a woman who has hyperthyroidism .

7 /2014 = Write a letter of referral to: Neurosurgeon for an urgent MRI and provide
necessary advice regarding the possibility of surgery of a man who has low back pain.

8 /2014 = Write a letter of referral to: Neurologist for further neurological assessment
of a man who has MS.

9 /2014 = Write a letter of referral to: The Admitting Officer at the Emergency Department
for urgent treatment of a man who has asthma and pneumonia .

10 /2014 = Write a letter of referral to: chest specialist for further treatment of a man who
has worsening asthma

11 /2014 = Write a letter of referral to: psychiatrist for further assessment and
management of a women with depression and anxiety .
TIME ALLOWED: READING TIME: 5 MINUTES January 2014
WRITING TIME: 40 MINUTES

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

notes:
Patient: Joshua Vance
Gender: Male
DOB: 17/11/13
Normal vaginal delivery at 38 weeks' gestation
No perinatal or neonatal complications
Birth weight 3250g

Parents: Pamela Vance (mother) - first child

Stewart Vance (father)

31/12/13 Routine 6-week baby check

History:
Mother concerned regarding bowel actions: only one bowel action every 3 days; stools a little hard. Is
breastfed. Making wet nappies, feeding well, demand feeding, sleeping through the night.

Examination:
6-week check - good tone, hands & feet normal, hips normal, genitalia male, no herniae, no evidence of
spina bifida occulta. abdominal/chest/heart exam normal.
fontanelles normal, red reflex present. nose & ear.s normal, palate intact.
Perianal examination normal, no fissures. Weight 3900g.

Assessment: Mild constipation in breastfed baby; otherwise normal 6-week check.

Plan: Reassurance - bowel habit variable in infants & can often settle. Try expressing milk from one feed a
day & giving it in a bottle with some water (boiled & cooled to body temp).
Review 2/52
13/01/14
History:
Still hard stools every 3 days. Now waking up crying, pulling legs up to chest every half hour throughout the
night. Pulls away from breast halfway through feeds. No vomiting. No fevers.
No respiratory symptoms. Making wet nappies.

Examination:
Hydration status normal.
Abdominal examination: hard faeces.
Perianal examination normal. no fissures.
Weight 4200g.

Assessment: Constipation no better. Has put on weight.

Plan:
Trial of Coloxyl drops daily. Express milk from two feeds a day & give ii in a bottle
with some water (boiled & cooled to body temp).
Review 1/52.

18/01/14
History:
Has not passed a bowel action for last 5 days. Refusing feeds. No wet nappies
today. Vomit x 1. No fevers.

Examination:
Irritable ½ week-old.
Mildly dehydrated: dry mucous membranes, tissue turgor & capillary return
normal: P 120; RR 30.
Abdominal examination: mild generalised tenderness, no guarding or rebound tenderness.
Weight 41 0Og.

Assessment Constipation & mild dehydration. Refusing feeds.

Plan:
Needs review at Children's Hospital ED for rehydration & further assessment regarding constipation.
Writing Task:
Using the information given in the case notes. write a letter of referral lo the Admitting Officer at the
Emergency Department, Children's Hospital. Newtown.

In your answer:
• Expand the relevant notes into complete sentences
• Do not use note form
• Use letter format

The body of the letter should be approximately 180-200 words.

Admitting Officer
Emergency Department
Children's Hospital
Newtown

18/01/14

Dear Doctor,

Re: Joshua Vance, DOB: 17/11/13

I am writing this letter to refer, an 8 and half-week-old baby who is suffering from constipation and
mild dehydration. Your further assessment would be highly appreciated.
Joshua Vance is the first child of his family. He was delivered normally with a birth weight of 3.25
kilograms at 38 weeks' gestation without any perinatal or neonatal complications.

On the routine 6-week baby check, his mother was worried regarding her baby's bowel movement
as he had been having only one bowel action every 3 days; therefore, his stool was a little hard.
Apart from the presence of red eye reflex, his examination was unremarkable. The mother was
reassured and encouraged to continue breastfeeding along with milk expression and mixing with
water to feed him. After 2 weeks, his earlier symptoms continued to deteriorate as he was waking
up crying and pulling his legs to chest every half an hour throughout the night. At that time, hard
feces were felt on abdominal examination; thus, a trial of Coloxyl drops was commenced daily.

Unfortunately, on today's visit, she reported that he has not passed any bowel action for the last five
days. Examination revealed tender abdomen with no guarding or rebound tenderness. In addition,
he was mildly dehydrated, showed small weight loss and had no wet nappies despite having normal
vital signs.

In view of the above, I believe he needs your review regarding his condition.

Yours faithfully,

Doctor
Word length 202
Admitting Officer
Emergency Department
Children Hospital
Newtown

18.01.2014

Dear Sir/Madam,
RE: Joshua Vance, D.O.B: 17.11.2013

I am writing this letter to urgently refer Joshua Vance, a 2 month-old full-term absolute breastfed
infant, as his mother has reported that he had not passed any stools for 5 days and he had poor
feeding pattern. Your immediate assessment and further management would be highly appreciated.
Or
Thank you for seeing Joshua, a 2 month-old full-term absolute breastfed infant, who has features
suggestive of constipation. Your further assessment would be highly acknowledged.
Initially, Joshua, who was born vaginally without any complications, presented with his mother to
me for his 6-week postnatal checkup. Although his physical examination showed no abnormalities,
his mother was utterly concerned about his poor bowel motion; as he was passing only one bowel
motion every 3 consecutive days. Therefore, I reassured her and advised her to try to express her
breast milk into a bottle and feed him with it after mixing the milk with previously boiled water.
Then, review two weeks later was arranged.

On review, unfortunately, Joshua’s condition had not improved. At that time, he started having
unbearable abdominal cramps every half an hour which was awakening him at night. Although his
cramps were severe, his physical examination was completely normal. Accordingly, a trial of Coloxyl
drops was prescribed along with expressing milk bottle feeds.

Today, Joshua’s condition became worse; he had an absolute constipation. Moreover, his physical
examination showed mild dehydration and generalised abdominal tenderness.

At this stage, a referral to the Emergency Department is urgently needed. If you need any further
information, do not hesitate to contact me.

Yours sincerely,
Doctor X
Admitting Officer
Emergency Department
Children’s Hospital
Newtown
13.01.2014

Dear Admitting Officer,

Re: Joshua Vance, DOB 17.11.13
Thank you for seeing Joshua, a 2-week-old male infant, who has recently developed constipation
with mild dehydration. Your urgent management would be highly appreciated.

Joshua, who was delivered vaginally at 38 weeks’ gestation with a birth weight of 3250g, is the first
child of his parents.

On 31.12.13, Joshua was brought for the routine 6-week check by his mother who was concerned
regarding his bowel action because it was once every 3 days; however, he was making wet nappies,
feeding well, demanding feeding and sleeping through the night. Therefore, the mother was advised
to express milk from one feed once daily and to give him in a bottle with some previously boiled and
cooled water.

Two weeks later, no improvement was noticed in his condition; furthermore, Joshua started to wake
up crying and pulling his legs up to his chest every half an hour at night. On abdominal examination,
there were hard faeces. As a result, a trial of Coloxyl drops daily was prescribed and the mother was
requested to express milk from two feeds daily.

On today’s visit, Joshua’s mother reported that he had not been passing a bowel action over the last
five days and he had been refusing feeds. Moreover, he stopped making wet nappies and vomited
once. On general examination, he was irritable, with a progressive weight reduction and mildly
dehydrated: he had dry mucous membranes, while on abdominal examination, there was mild
generalized tenderness; however, neither guarding nor rebound tenderness was noticed.

Based on this, Joshua is being referred for rehydration and further assessment. Should there be any
queries, please do not hesitate to contact me.

Yours sincerely,
Doctor X
TIME ALLOWED: READING TIME: 5 MINUTES February 2014
WRITING TIME: 40 MINUTES

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

notes:
Mr Daniel McCrae is a patient in your general practice.
History:
DOB: 17 October 1962
Height: 180cm
Weight: 91kg
BMI: 28.1

Social background:
Smoker
Married, 4 children (23, 20, 10, Byrs)
Barrister

Hobbles: Reading, cooking, art, music

19/09/13: Pt fever, sore throat. cough, headache, body aching

Wants antibiotics so no need for time off work - v busy

0/E:
BP 120/75
Heart rate 76bpm
Chest clear
Wt 91kg
BMI 28.1
Temp 38.9°C

Tests: None

Assessment: Viral infection

Plan:
Rest 1·3 days until fever subsides. symptoms weaken Paracetamol
R/V if symptoms persist >5 days
08/02/14:
0/E:
Pt feeling tired. ·ott-colour'. as if never fully recovered from infection (Sep 2013).
Complains of ·unsettled system' for several weeks - abdominal discomfort. gas.
diarrhoea/constipation; feels fatigued. Still under some stress from workload.
No family history of colorectal carcinoma. colonic polyps or inflammatory
bowel disease.
BP 115/80
Heart rate 77bpm
Wt 92kg
BMI 28.4
Temp 31.1°c

Abdomen soft. lax. no masses. no guarding or rebound

Normal bowel sounds

Assessment:
? Irritable bowel syndrome
? Crohn's disease. ulcerative colitis, inflammatory bowel disease
? Unfit. Overweight

Plan:
Investigations: CBC
Faecal occult blood test (FOBT)
Colonoscopy
R/V in 2 weeks for test results

22/02/14:
0/1E: Pt still feeling unwell
BP 120/85
Heart rate 74bpm
Chest clear
Temp 37°C
No abdominal mass

Results:
CBC: normal. WBC (8.5), , Hb (91 ), t Hct (34%)
FOBT: positive
Colonoscopy: abnormal. Malignancy detected in ascending colon; biopsy taken and adenocarcinoma
diagnosed
Assessment:
Adenocarcinoma of the ascending colon

Plan: Refer to colorectal surgeon for assessment ASAP

Writing Task:
Using the information given in the case notes. write a letter of referral to: Associate Professor Simon
Anderson, Surgeon, Suite 65. City Hospital. 25-29 Main Road. Centreville.

In your answer:
• Expand the relevant notes into complete sentences
• Do om use note form
• Use letter format

The body of the letter should be approximately 180-200 words.

Associate Professor Simon Anderson
Surgeon
Suite 65
City Hospital
25-29 Main Road
Centreville

22/02/14

Dear Doctor Anderson

Re: Mr. Daniel McCrae, DOB: 17/10/1962

I am writing this letter to refer this patient, a 52-year-old male whose features are suggestive of
adenocarcinoma of the ascending colon. Your management would be highly appreciated.

Mr. McCrae is a married barrister with 4 children. He is a smoker and has no family history of
colorectal carcinoma or colonic polyps.

On 19/09/13, the patient visited my clinic complaining of typical symptoms of viral infection;
therefore, he was advised to rest and take Panadol for his fever. Four months later, he reported
having abdominal discomfort, change in bowel habits and fatigue for the past several weeks. The
patient was ill looking despite the unremarkable abdominal examination. As a result, CBC, Fecal
occult blood test (FOBT) and colonoscopy were ordered to rule out any suspicion of bowel cancer or
inflammatory bowel diseases.

Unfortunately, on today's visit, the Investigations showed decreased Hb, positive FOBT and
adenocarcinoma of the ascending colon which was diagnosed through taking a biopsy during
colonoscopy.

In view of the above, I believe this patient needs your urgent assessment. For any queries, please do
not hesitate to contact me.

Yours sincerely

Doctor
Word length 180
Associate Professor Simon Anderson
Surgeon
Suite 65
City Hospital
25- 29 Main Road
Centreville

15.02.2014

Dear Dr. Anderson,

Re: Mr. Daniel McCrae, DOB 17.10.1962

Thank you for seeing Mr. McCrae, a 62-year-old barrister, who has been recently diagnosed with
adenocarcinoma of the ascending colon. Your surgical assessment would be highly appreciated.

Mr. McCrae is married, and has 4 children. He is a smoker; however, there is no family history of
colorectal carcinoma, colonic polyps or inflammatory bowel disease. Initially, Mr McCrae presented
to the clinic with an attack of chest infection which was treated symptomatically.

On 08.02.14, Mr. McCrae reported that he had been suffering from abdominal discomfort, gases,
diarrhea shifted with constipation and fatigue. On examination, he was overweight; however, his
vital signs were normal. His diagnosis was unclear; therefore, some investigations were ordered
including a complete blood count, faecal occult blood test (FOBT) and colonoscopy.

On today’s visit, Mr. McCrae reported being unwell. Additionally, his investigations revealed anemia
as well as a decrease in the white blood cell count and a positive FOBT while the colonoscopy result
revealed a malignancy detected in the ascending colon. Therefore, a biopsy had been taken and he
has been diagnosed with adenocarcinoma in the ascending colon.

Based on the above information, I am referring Mr. McCrae for further assessment as soon as
possible. Should be any queries, please do not hesitate to contact me.

Yours sincerely,

Doctor
Dr. Simon Anderson
Associate Professor
Surgery Department
City Hospital
25-29 Main Road
Centreville

22nd February 2011

Dear Dr. Anderson

Re: Mr. Daniel McCrae, D.O.B: 17th October

Thank you for seeing Mr. McCrae, a 52-year-old barrister, who has been recently diagnosed with
adenocarcinoma of the ascending colon.

Mr. McCrae is a married gentleman with four children. He has been a patient of mine for a long
time. He first came to me on 14.09.2013 with a complaint of an attack of chest infection, which was
treated symptomatically.

Five months later, Mr McCrae presented with abdominal discomfort, fatigue and alternating
diarrhea with constipation. On examination, his abdomen was lax without palpable masses. With
regard to the risk factors, he has no family history of colorectal cancer. Therefore, some
investigations were arranged.

Today, 27.01.2014, when Mr McCrae attended the clinic, there was no improvement in his
condition. Plus, he came with the results investigations which were disappointing. To illustrate, his
FOBT was positive and adenocarcinoma of the
ascending colon was detected after colonoscopy and biopsy had been done. Please note that his
blood tests showed anemia and today’s examination was unremarkable.

In view of the above, I am referring Mr. McCrae for an urgent surgical assessment. Should you have
any further queries, please do not hesitate to contact me.

Yours sincerely

Doctor X
TIME ALLOWED: READING TIME: 5 MINUTES March 2014
WRITING TIME: 40 MINUTES
Doctor Susan Clayton
Endocrinologist
Women's Health Center
11-13 Bell Street
Newtown

28/03/14

Dear Doctor Clayton,

Re: Mrs. Tracy Bowen, DOB: 22/07/88

I am writing to refer this patient, a 26-year-old married women whose features are suggestive of a
possible polycystic ovarian syndrome diagnosis.

Mrs. Bowen has been a patient of mine for the past 9 years. she has a medical history of asthma
which has been managed accordingly.

On her first visit, on 28/8/04, She presented complaining of irregular, infrequent menstrual cycles.
Her periods were also associated with dysmenorrhea; therefore, she was commenced on OCPs and
analgesia. Three weeks later, the patient attended with a new complaint of acne over multiple areas
of her body. Examination showed, deep inflamed nodules and pus-filled cysts. As a result, she was
managed with antibiotics which did not help. consequently, she was referred to a dermatologist.

On review today, the patient requested to be referred to an endocrinologist as she has been having
difficulty in conceiving after OCP cessation since January 2013, amenorrhea and weight gain.
Investigations showed decreased level of vitamin D and elevated levels of androgens, prolactin and
oral GGT; thus, Climen was prescribed.

In light of the above, I am referring her for your further assessment. Please note, a copy of her pelvic
US will be sent.

Yours sincerely,

Doctor

Word length 211

Dr. Susan Clayton
Endocrinologist
Woman’s Health Center
11-13 Bell Street
Newtown
28/03/2014
Dear Dr. Clayton
Re: Miss Tracy Bowen, D.O.B: 22/07/1988

Thank you for seeing Miss Bowen, a 26- year- old lady, who has presented with symptoms suggestive
of PCOS.
Miss Bowen is known to be asthmatic which is aggravated by exercise and upon exposure to dust,
smoke, cat fur or weather changes. Plus, she has a history of recurrent bronchitis. Consequently, she
is on salbutamol and beclomethasone inhalers. It is worth mentioning that she lives in a smoky
atmosphere as her father is a heavy smoker. Regrettably, she has been living under stress for 12
years because of her parent’s divorce.
Miss Bown has been a patient of mine since 28/08/2004 when she presented with irregular, painful
and infrequent menses. Further, she suffered from adolescent acne. Her physical examination was
completely normal, so that she was diagnosed with idiopathic oligomenorrhea and primary
dysmenorrhea for which she was prescribed Diane and analgesia after reassuring her. On
21/09/2005, she presented with deep inflamed acne which required oral and topical antibiotics
treatment. Two months later, she came back with no improvement. Moreover, the condition was
complicated by scar formation which let me refer her to a dermatologist for isotretinoin treatment.
Today, Miss Bown presented to the clinic, after she had been married, with a different complaint. To
illustrate, she has been suffering from amenorrhea with subsequent failure to conceive. Additionally,
she noted that she had had electrolysis for hirsutism. Being overweight together with her hormonal
assay results; high free androgen index, high FBS and hyperprolactinemia made PCOS diagnosis
highly suspected. Consequently, Climen was prescribed and pelvic ultrasound was arranged. Based
upon the patient’s request, a referral to an endocrinologist was done.
In view of the above, my provisional diagnosis is PCOS. Your further evaluation and management
would be highly appreciated. Kindly check the attached copy of the laboratory results. Please,
contact me for more queries.
Yours sincerely
Doctor
TIME ALLOWED: READING TIME: 5 MINUTES May 2014
WRITING TIME: 40 MINUTES

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

notes:
Mr James Seymour is a 60-year-old man presenting in your general practice with a swollen left large toe.
Patient details:
Name: James Seymour
Residence: 4 Pawlet Drive, Clayfield
DOB: 19/09/53 (Age 60}

Social history:
Retired academic (computer science}
Divorced, no children, lives alone
Non-smoker since 1994
Heavy drinker 5-6 beers and 3 wines/day

Observations: BP 115/70mmHg, HR 68, RR 18, T 37.4°C

Allergies: Nil known

FHx:
Father - rheumatoid arthritis (RA)~ 28 yrs old. Died 75yrs.
Mother - smoker, died chest infection aged 71 yrs.
Grandparents' history unknown, died when old.

PMHx:
Appendicectomy 1963
Childhood - recurrent bronchitis
Annual influenza vaccine
Regular episodes of inflammation (?gout 1st toe) since 2010 – consulted several doctors

Medication:
Colchicine (Lengout) - 500mcg 2 tabs (stat on attack) then 1 tab each 2/24 until relief. Total dose~ 6mg in 4
days.
lndomethacin (lndocid} - 25mg 2 tabs, twice/day.
On allopurinol after last acute attack - after several mths w/o symptoms ceased meds (a couple of mths
before current episode).
Treatment record:
25/04/14 ~4 wks into current bout of gout.
Colchicine started 2 wks into bout, only taken at sub-therapeutic levels.
lndocid taken erratically.
3rd bout in 8 mths.
No allopurinol for a couple of mths.
Modifies diet to decrease purines. Sometimes wakes at night.
Given father's Hx Pt wants referral to rheumatologist to exclude RA.
Pt thinks gout meds not working (unlikely).

On examination:
Moderately inflamed, red first L toe. V painful - Pt irritated. No evidence of involvement of other joints.
pt V insistent on possibility of RA; poor compliance with gout management much more likely.
Treatment:
• Encouraged to comply with gout meds:
- resume full dose colchicine.
- resume full dose indomethacin. Cease either if gastrointestinal (GI) side effects (diarrhoea from colchicine;
upper GI upset from indomethacin).
• Regular paracetamol (4g/day for 3 days, then prn).
• Take oxycodone 5mg bedtime only if sore and can't sleep; try to cease ASAP.
• Improve dietary compliance and • alcohol intake.
• X-ray L foot, FBE, ESR, LFT, U&E, SUA, CRP.
• Rev. 1/52 to discuss results & referral.

03/05/14
X-ray - minor degenerative changes of L first metatarsophalangeal joint.
FBE: MCH 32.3pg (Ref Range: 27.0 - 32.0). All other NAO.
urate 0.48mmol/L (Ref Range: 0.18 - 0.47mmol/L).
CRP 6.0mg/L (Ref Range:< 3.0).
Gout episode subsiding.
No drug side effects apart from brief diarrhoea.
Only needed night time oxycodone 3 nights.

Provisional Diagnosis: Gout.

Treatment:
Discussed ?synovial fluid sample stat next episode.
Start allopurinol now, long term; reinforce messages re: diet & alcohol.
Referral to Rheumatologist on patient's insistence with copy of pathology results.
Writing Task:
Using the information given in the case notes, write a letter to Dr Malcolm Still, Rheumatologist at 5 Grant
St, Fairmont, for further treatment or investigations.

In your answer:
• Expand the relevant notes into complete sentences
• Do om use note form
• Use letter format

The body of the letter should be approximately 180-200 words.

Dr. Malcom still
Rheumatologist
5 Grant Street
Fairmont

3/05/2014

Dear Dr. Still,

Re: Mr. James Seymour, DOB: 19/09/1953

I am writing this letter to refer Mr.Seymour, a sixty-year-old retired academic whose features are
suggestive of gout.

Mr. Seymour is a heavy drinker. According to his medical history, he has had several episodes of
inflammation of the first toe since 2010. Therefore, the patient was commenced on colchicine and
indomethacin as well as allopurinol which was prescribed after the last acute attack. Please note, he
has no known allergies , and he has a family history of rheumatoid arthritis.

On 25/04/14, the patient presented with a 4-week history of a swollen left large toe which was his
third episode of gout in the last 8 months. Additionally, he reported ceasing his medications a couple
of months ago. However, 2 weeks after this episode he resumed colchicine. On examination, the
first toe was red and moderately inflamed. As a result, full doses of colchicine and indomethacin
were resumed. Imaging studies and blood tests were also ordered.

On review today, his symptoms had subsided. However, the patient thinks he has RA due to his
positive family history. X-ray showed minor degenerative changes of the left toe while FBE revealed
elevated urate and CRP levels .

In light of the above, I would be grateful if you could manage this patient as you think appropriate.
If you require any further information, please do not hesitate to contact me.

Yours sincerely,

Doctor

Word length 203

Dr. Malcolm Still
Rheumatologist
5 Grant Street
Fairmont.

3/1/2018

Dear Dr. Still,

RE: James Seymour DOB: 19/9/1953

Thank you for seeing Mr. Seymour, a 60-year-old retired academic, presenting with symptoms and
signs suggestive of gout.
Mr. Seymour is divorced, living alone. He doesn’t smoke ex-smoker, however, he is a heavy drinker.
Regarding medical history, his father had Rheumatoid arthritis. his mother died by of a chest
infection aged 71-year-old. He had an appendicectomy operation; or , and he had recurrent
bronchitis during childhood. Thus he administers Annual Influenza Vaccine.

Initially, he presented by with regular episodes of gout, that is why he was commenced on
Colchicine, Indomethacin, in addition to Allopurinol prescribed after last acute attack. His
medications on 25/4/2014 included Colchicine at sub-therapeutic levels along with Indocid. Also, his
diet was modified to decrease Purines.

On examination, his first left toe was moderately inflammed inflamed and painful. Accordingly, he is
advised to continue on Colchicine and Indomethacin. However, they would be discontinued on
having Gastrointestinal adverse effects. Furthermore, regular paracetamol would be administrated
and also oxycodone on demand only.
Finally, on 3/5/2014 he had investigations including rising CRP and x-ray revealing degenerative
changes of the left metetarsopharyngeal metatarsophalangeal joint.

I believe his condition is getting progressively worse. Please consider starting Allopurinol and
encourage regulating diet and alcohol along with massage reinforcement. I am also requesting
having Synovial fluid sample being assessed. You further management would be much appreciated.
Yours Sincerely,
Doctor
Total Words: 233
Dr. Malcolm Still
Rheumatologist
5 Grant Street
Fairmont.

3/1/2018

Dear Dr. Still,

RE: James Seymour

Thank you for seeing Mr. Seymour, a 60-year-old man, presenting with symptoms and signs
suggestive of gout.

Mr. Seymour drinks heavily. Furthermore, his father had rheumatoid arthritis. He had several gouty
attacks for which he was prescribed colchicine and indomethacin in addition to allopurinol.

On 25/4/2014 patient came with his third attack of gout for which he was taking a suboptimal dose
of both colchicine and indomethacin, Also, he stopped his allopurinol few months after his previous
attack. On examination, his first left toe was inflamed and painful. Accordingly, he was advised to
take a full dose of both colchicine and indomethacin unless he developed adverse effects.
Furthermore, regular paracetamol prescribed and oxycodone at bedtime on demand only. Also,
patient advised decreasing his alcohol consumption alongside dietary control. Imaging and
laboratory investigations ordered.

During the last visit, patient investigations showed mildly elevated CRP which indicate the resolution
of the attack. Furthermore, synovial fluid planned for next attack plus regular allopurinol
prescription, In addition to emphasizing the importance of lifestyle modification.

I believe that Mr. Seymour had gout. However, he is worried as he thinks he had rheumatoid
arthritis like his father. I would like to refer him to you for further evaluation and investigations.

Yours Sincerely,

Doctor
Dr. Malcolm Still
Rheumatologist
5 Grant Street
Fairmont

03/05/2014

Dear Dr. Still,

Re: Mr. James Seymour, DOB: 19/09/1953

Thank you for seeing Mr. Seymour, a 60-year-old retired academic, who has been suffering from
features suggestive of gout. Your further evaluation would be highly appreciated.

Mr. Seymour is divorced with no children, and lives alone. He has quit smoking since 1994; however,
he is a heavy drinker. Regarding his medical history, he has been suffering from regular episodes of
inflammation in his first toe, which was diagnosed as gout in 2010, for which he was prescribed
colchicine, to be taken during the attack, indomethacin and allopurinol which was started after the
last attack with no improvement to his symptoms. Additionally, his father was diagnosed with
rheumatoid arthritis at the age of 28.

On 25/04/14, Mr. Seymour presented with a new bout of the same complaint of 4 week duration
and it was the third one during the last eight months. Unfortunately, colchicine was taken at sub-
therapeutic levels. On examination, his left first toe was moderately inflamed and painful. As a
result, he was prescribed paracetamol and oxycodone, and he was encouraged to comply with his
medications and improve his dietary compliance by decreasing both purines and alcohol. Kindly
note, some significant investigations were ordered.

Today, the results revealed minor degenerative changes of the left first metatarsophalangeal joint
on the x-ray, while the FBE showed a mild elevation in the mean corpuscular hemoglobin, urate was
mildly elevated and CRP was highly elevated. Therefore, he has been diagnosed with gout and was
prescribed allopurinol. I discussed with him the probability of taking a synovial fluid sample on the
next episode.
For further queries, please do not hesitate to contact me.

Yours sincerely,

Doctor
TIME ALLOWED: READING TIME: 5 MINUTES June 2014
WRITING TIME: 40 MINUTES
Dr. Charles White
endocrinologist
Bayview Private Hospital
81 Canyon Road
Bayview

31/05/14

Dear Doctor,

Re: Lola Duval

DOB: 27/05/1990

I am writing to refer Mrs. Duval, a 24-year old engineering student, whose features are consistent
with hyperthyroidism. Your further management is highly appreciated .
Regarding her medical history, she has been suffering of laryngitis and due to the anxiety and
insomnia, sleeping pills has been taken occasionally. Please note, her mother suffers from depression.
First presented to me on 31/05/14. complaining of unexplained loss of weight over last two months
in spite of eating well. On examination, she was look thin and her body weight was 55 kg . she has
tremor, exophthalmos with eyelid lag was detected ; therefore, ECG and some investigations were
requested.
On today’s consultation, Mrs. Duval came reporting that is still felling unwell . Her investigation has
been showed high thyroid hormones ,low TSH ,but normal blood count, renal function and serum
electrolytes. sinus tachycardia was detected in ECG. the results of investigation was discussed with a
patient. furthermore, the thyroid auto antibodies and thyroid scan were requested.
In view of the above, my provisional diagnosis is hyperthyroidism most likely graves’ disease ;
therefore, I would appreciate your further assessment and management. please do not hesitate to
contact me for any assistance you require regarding this patient.

Yours sincerely,

Doctor

Word Count: 190 words

Dr. Charles White
Thyroid Specialist
Bayview Private Hospital
81 Canyon Road
Bayview

1/06/2014

Dear Dr. White

Re: Ms. Lola Duval, DOB: 27/05/90

I am writing this letter to refer, a 24-year-old female engineering student who is presenting with
signs and symptoms suggestive of hyperthyroidism due to Grave's disease.

Ms. Duval has a medical history of anxiety and insomnia for which she takes sleeping pills
occasionally.

On 31/05/14, the patient visited my clinic complaining of unexplained weight loss over the previous
2 months despite her good appetite. She also reported having tremors, palpitations, sweating and
heat intolerance. On examination, her vital signs were in the normal range. However, a non-tender
slightly enlarged thyroid gland as well as tremors in both hands were noticed. Additionally, eye
examination revealed some exophthalmos with lid lag. Therefore, blood tests, ECG and TFT were
ordered.

Unfortunately, on review today, her TFT results showed elevated T3 and T4 with low TSH while ECG
showed sinus tachycardia. As a result, thyroid auto-antibodies plus thyroid scan were ordered.
In view of the above, I am referring her for your further management. Please note, she is anxious
about her condition and needs an early review. For any queries, please contact me.

Yours sincerely

Doctor

Word Count: 178 words

Dr Charles White
Thyroid Specialist
Bayview Private Hospital
81 Canyon Road
Bayview
01/06/2014

Dear Dr White,
Re: Ms Lola Duval
D.O.B: 27/05/1990
Thank you for seeing Ms Duval, a 24-year-old student whose features are suggestive of Grave’s
disease. Your further assessment and management would be highly appreciated.
In terms of Ms Duval’s medical history, she has had laryngitis for two years and has been suffering
from anxiety and insomnia.
Yesterday, Ms Duval attended the clinic and informed me that she had lost 10 kgs over the last 2
months despite having a good appetite and eating well. After further discussions, she reported that
she had been experiencing tremors, palpitations, sweating and heat intolerance over the same
period and those complaints have been recently associated with fatigue.
Ms Duval’s examination revealed a slight non-tender enlargement of the thyroid gland as well as fine
tremors in her hands. Furthermore, there were exophthalmos and lid lag on the eye examination. At
that time, hyperthyroidism was suspected; therefore, thyroid functions and electrocardiography
(ECG) were ordered. Further, other blood tests were arranged.
Today, unfortunately, her thyroid functions confirmed the diagnosis; as they showed a decrease in
the TSH level along with elevated free T3 and T4. Moreover, the ECG indicated sinus tachycardia. As
a result, thyroid auto-antibody tests and a thyroid scan were ordered after discussing the likely
diagnosis with her.

In view of the above, my provisional diagnosis at this point is Grave’s disease type of
hyperthyroidism. Thus, I am referring her to you for an early review as she is utterly concerned
about her condition. For more queries, please do not hesitate to contact me.

Yours sincerely,

Doctor
TIME ALLOWED: READING TIME: 5 MINUTES July 2014
WRITING TIME: 40 MINUTES

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

notes:
Patient:
Mr George Poulos is a 45-year-old man who has hurt his back. He presented at your general practice surgery
for the first time in late June.

21/06/14
Subjective:
Severe lower back pain of 2 days duration:
2 days ago at home lifting logs (approx. weight each 20-30kg) from ground
into wheelbarrow.
Action: bending, lifting and rotation.
Sudden severe pain - mid lower back. Thought he felt a click.
Was locked in semi-flexed position, almost impossible to walk.
Wife helped him into house and bed.
Took 2x Panadeine Forte, repeated 4 hours later.
Disturbed sleep.
Pain only low back, no radiation to thighs.
Yesterday pain less severe, able to ambulate around house.
Today again pain less severe.

Patient History:
Stockbroker - 45 y.o.
Married - 3 children secondary school, 1 primary school.
App: Good. Diet irregular.
Bowels: Normal. Diarrhoea if stressed.
Mict: Normal.
Wt: Varies - BMI 27.
Sex: Often too tired.
Exercise: Nil.
Tobacco: 25/day.
Alcohol: Frequently 10+ to 15+ std drinks/day.

Allergies: Pethidine, penicillins, radiographic contrast agent (unspecified) ?? iodine.

Family History:
No Ca bowel, no diabetes, no cardiovascular.
HPI: Head injury (football) approx 15yrs ago. MRI brain. NAO.
Reacted to contrast medium.

Objective:
Full examination.
CVS, RS,RES, CNS:NAD.
P 68bpm reg. BP 135/80.
Musculo-skeletal: Stands erect. No scoliosis.
Loss of lumbar lordosis.
Lumbar spine: Flexion fingertips to patella. Expression of pain.
Extension limited by pain.
Lateral flexion: L & R full.
Rotation: L & R full.
No sensory loss.
Reflexes: Patellar & Ankle L+ R+.
SLR (straight leg raise): L 90 R 90.

Plan:
Take time off work. Analgesia: paracetamol 500mg 2x 4hrly max 8 in 24hrs or Panadeine Forte, or 1 of each.
Warned - risk of constipation with Codeine.
Review 1 week.

28/06/14 : Has now developed pain which extends down back of R thigh, lateral calf and into dorsum of
foot.
Objective:
Examination. As before except that now lumbar flexion limited to fingers to mid thigh and SLR: L 85 R 60.
Review 1 week.

05/07/14
Pain worse. Almost immobile. Severe pain down R leg. Tingling in R calf.
Objective:
Examination. Lumbar flexion almost nil. Other movts more restricted by pain. SLR: L 70 R 50.
Loss of light touch sensation lateral distal calf & plantar aspect of foot.
Loss of R ankle reflex.
Diagnosis: Low back pain, probably discogenic, with radiculopathy.
Refer to neurosurgeon & request that the neurosurgeon order an MRI and
provide advice regarding the possibility of surgery.
Writing Task:
Using the information given in the case notes, write a letter of referral to Dr~ White, Neurosurgeon,
City Hospital, Newtown.

In your answer:
• Expand the relevant notes into complete sentences
• Do om use note form
• Use letter format

The body of the letter should be approximately 180-200 words.

Dr. B White
Neurosurgeon
City Hospital
Newtown

05/07/14

Dear Dr. White,

Re: Mr. George Poulos

I am writing this letter to refer Mr. Poulos, a 45-year-old male whose features are suggestive of
lower back discogenic radiculopathy.

Mr. Poulos is a married stockbroker. He is a smoker and drinks alcohol. Moreover, the patient is
allergic to pethidine, penicillin and un unknown radiographic contrast agent.

On 21/06/14, the patient attended my clinic complaining of a sudden severe lower back pain that
began after bending his back to lift heavy logs from the ground. His examination showed an
expression of back pain on extension and flexion. Therefore, he was advised to rest and take
paracetamol. After one week, the pain extended to the back of his right thigh, lateral calf and
dorsum of the foot. At that time, his examination revealed worsened lumbar flexion and decreased
angle in the SLR test from 90 to 85 plus from 90 to 60 in the left and right leg, respectively.

Unfortunately, today, his pain has deteriorated even more as he is now nearly unable to perform
lumbar flexion. Additionally, loss of light touch sensation in the lateral distal calf and plantar aspect
of the foot was noticed.

In view of the above, I am referring this patient to see if he requires any surgical intervention.
Please note, he needs an MRI scan.

Yours sincerely,

Doctor

Word Count: 208 words

Dr. B White
Neurosurgeon
City Hospital
Newton
5th July 2014
Dear Dr. White,
Re: Mr. George Poulos, Age: 45 years
I am writing to refer Mr. Poulos, whose features are consistent with possible discogenic low back
pain along with radiculopathy. Your further assessment would be highly appreciated.
Mr. Poulos is a stockbroker, chain smoker and heavy drinker. Please note, he is allergic to pethidine,
penicillins and radiographic contrast agent.
Initially, on 21/06/14, he presented to me with sudden severe lower back pain for 2 days following
lifting logs from the ground to a wheelbarrow. Moreover, he was locked in a semi-flexed position
and could not walk at all. However, the pain was localized and he took Panadeine Forte for this. On
examination, his internal flexion was full, SLR was normal (L90, R90) and sensory functions along
with the ankle and patellar reflexes were intact. Therefore, time off from work was advised and
paracetamol was prescribed instead of codeine.
On the next visit, his pain had worsened with radiation and reduced SLR. Thus, a review in 1 week
was advised.
Today, His condition deteriorated with severe pain in the right leg with tingling sensation in the right
calf. Furthermore, the right ankle reflex was lost with loss of light touch sensation on the lateral
distal calf and the planter aspect of foot. Additionally, SLR was reduced significantly (L70, R50).
In view of the above, it would be greatly appreciated if you could assess this patient, order for an
urgent MRI and provide necessary advice regarding the possibility of surgery.
Yours sincerely,
Doctor
Word Count: 234words
Dr B White
Neurosurgeon
City Hospital
Newtown

05/07/2014

Dear Dr White

Re: Mr George Poulos, 45 years of age

Thank you for seeing Mr Paulos, a 54-year-old stockbroker whose features are suggestive of
discogenic low back pain. Your further assessment and management would be highly appreciated.

Mr Poulos, who is a married and has three children, is a heavy smoker and drinker. Moreover, he is
overweight and does not do exercises. Please note, he is allergic to pethidine, penicillin and an
unspecific radiographic contrast.

On 21/06/2014, Mr Poulos presented with severe low back pain which had been present for two
days after lifting heavy logs. His examination was unremarkable except for pain with flexion of the
fingertips to patella and with extension which was limited. Therefore, he was advised to rest and a
pain killer was prescribed.

A week ago, Mr Poulos attended the clinic, and reported that he had developed radicular pain
extending down the back of his right limb. On examination, his lumbar flexion and SLR were more
limited.

Today, Mr Poulos informs me that he has been almost immobile because of the pain. Furthermore,
his light touch sensations in the lateral distal calf and the plantar aspect of foot as well as the right
ankle reflex are limited.

In view of the above, my diagnosis at this point is discogenic low back pain which requires an MRI.
Thus, I am referring him to you for your further assessment, management and possible surgery if
needed.

Yours sincerely
Doctor
TIME ALLOWED: READING TIME: 5 MINUTES August 2014
WRITING TIME: 40 MINUTES

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

notes:
Michael Weir is a patient in your general practice.
Name: Mr Michael Weir (DOB: 20 Sep 1970)
Height: 183cm
Background:
Smoker
Overweight - long term
Depression - sertraline hydrochloride (Zoloft) since Sep 2012
Married - 3 children (13, 10 & 8yrs)
Real estate agent - reports no time for exercise/relaxation
Active member of local church congregation

Patient History:
29.06.14
Subjective: Here for general check-up. Reports feeling 'run down': tired, stressed, 'sluggish'.
Examination: BP: 96/83, Heart rate (HR): 70bpm
BMI: 27.8 (Wt: 93.1kg)
Chest clear
Skin check - no suspicious lesions found
Tests: CBC, cholesterol/lipids
Plan: R/v in 1wk (discuss test results)

07.07.14
Subjective: Here to receive results of blood tests (cholesterol, CBC)
Still tired, feeling 'down'.
Reports weakness in L leg.
Examination: BP: 90/80, HR: 79 bpm
Chest clear
Test results:
Sertraline hydrochloride - ongoing
BMI: 28.5 (Wt: 95.5kg)
Cholesterol: 6.37mmol/L
CBC - low WBC; low RBC, low Hb & Hct; other results in normal range
Assessment:
Repeat assessment of hypercholesterolaemia in 3mths.
Plan:
Monitor general health - tiredness, depressed feelings.
Pt should make lifestyle changes (smoking, diet, exercise, recreation).
Pt to decrease dietary saturated fat, incorporate regular exercise to decrease Weight & cholesterol
levels; stop smoking.
R/V in approx 1mth to assess general health, feelings of tiredness & being 'down'.

09.08.14
Subjective: Complains of dizziness and reports two recent 'blackouts' (a few minutes each).
Feels stressed - busy at work. Mood up and down since last visit. Reports tingling
in hands. L leg still feels weak. Breathless, occasional constipation, short of energy.
Has been trying to eat better & exercise more - walks (30mins) x2-3/week.
Still smoking.
Examination: BP: 88/70, HR: 76bpm
BMI: 28 (Wt: 93.7kg)
Chest clear
Tests:
Loss of sensation on L & R hands (sharp/blunt)
Reflexes - diminished L patellar reflex
Order head & lumbar spinal CT to try to determine cause(s) of leg weakness and associated objective
hyporeflexia (?central or spinal - check for spinal cysts/ tumours, etc.).
Assessment: ?multiple sclerosis
Plan: Order CT
Refer to neurologist: a full neurological assessment; ?order MRI

Writing Task:
Using the information given in the case notes, write a letter of referral to Dr M Mclaren,
Neurologist, Suite 3, 67 The Crescent, Newtown.
In your answer:
• Expand the relevant notes into complete sentences
• Do om use note form
• Use letter format

The body of the letter should be approximately 180-200 words.

Dr. M McLaren
Neurologist
Suite 3
67 The Crescent
Newtown

09/08/14

Dear Dr. McLaren,

Re: Mr. Michael Weir, DOB: 20/09/1970

I am writing this letter to refer Mr. Weir, a 43-year-old married man, whose features are suggestive
of multiple sclerosis.

Mr. Weir is a smoker and has had depression since September 2012, for which he takes Zoloft.

On 26/06/14, the patient attended my clinic complaining of fatigue and stress. His examination was
unremarkable except for a BP of 96/83 and high BMI (27.8). Therefore, CBC and lipid tests were
ordered.
After one week, on results day, he reported having weakness in his left leg. Test results showed
decreased levels of WBC, RBC, Hb and Hct, whereas his cholesterol level was 6.37 mmol/L; thus, the
patient was advised to decrease saturated fat intake and to exercise in order to lose weight.

Unfortunately, today he presented with dizziness and two recent blackouts as well as a tingling
sensation in his hands. His examination revealed a loss of sensation on both hands plus a diminished
left patellar reflex. As a result, CTs of the head and lumbar spine were ordered, however, an MRI
might also be needed.

In view of the above, I am referring this patient for your further neurological assessment. Please do
not hesitate to contact me

Yours sincerely,
Doctor

Word Count: 188 words

Dr. M McLaren
Neurologist
Suite 3
67 The Crescent
Newtown

09.08.2014

Dear Dr. McLaren,

Re: Mr. Michael Weir, DOB 20 September 1970

Thank you for seeing Mr. Weir, a 44-year-old real estate agent, who has been recently diagnosed
with probable multiple sclerosis. Your further assessment would be highly appreciated.

Mr. Weir is married, and has 3 children. He has an unhealthy lifestyle: he is a smoker as well as an
overweight man because he has neither time for exercise nor relaxation. Furthermore, he has a
medical history of depression, for which he is currently on Zoloft.

On 29.06.2014, Mr. Weir attended the clinic for a general check-up. In addition, he reported that
he had been feeling tired, stressed and lazy. Furthermore, he experienced a feeling of weakness in
his left leg. Based on this, investigations were ordered and he was diagnosed with
hypercholesterolemia. Because of this, he was requested to decrease his dietary saturated fat,
incorporate regular exercise, and stop smoking.

On today’s visit, Mr. Weir complained of dizziness and two fainting attacks: each of which has
sustained for few minutes. Moreover, he reported tingling in his hands with a continuation of his
left leg weakness. On examination, there was loss of sensation on the left and right hands, and a
diminished left patellar reflex was noticed. Therefore, head and lumbar computed tomography
were requested.

In view of the above, Mr. Weir is being referred into your care for a full neurological examination
and for a magnetic resonance imaging, if needed.

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

Yours sincerely,
Doctor
Dr. M Mclaren
Neurologist
Suite 3
67 The crescent
Newtown

09th of August 2014

Dear Dr. Mclaren

Re: Mr. Michael Weir, D.O.B: 20 September 1970

Thank you for seeing Mr Weir, a 44-year-old real estate agent, who has features suggestive of
multiple sclerosis.

Mr. Weir has been a patient for a long period of time. He is married, and has 3 children. His medical
records reveal that he has been overweight, smoker and under treatment for depression with
sertraline.

At first, he came to me on 29.06.2014 for a general check-up when he reported feeling of tiredness
and stress. For that, some blood tests were arranged. One week later, he attended for the tests'
results which confirmed the presence of anemia and hypercholesterolemia. Additionally, he
reported weakness of his left leg. Therefore, he was given lifestyle changes advice and I urged him to
quit smoking.

Today, 09.08.2014, he presented to me when he complained of dizziness, stress and recent

blackouts. On examination, he had left leg weakness, loss of sensation in both hands and a
diminished left patellar reflex.

Based on the above data, my provisional diagnosis is multiple sclerosis; hence, a CT scan of head and
lumbar spines was requested. He was referred into your care for full neurological assessment and to
assess the need for an MRI. Thank you for your care. For further queries, please contact me.

Yours sincerely

Doctor
TIME ALLOWED: READING TIME: 5 MINUTES September 2014
WRITING TIME: 40 MINUTES

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

notes:

Patient: Sally Mcconville (Ms), aged 38

Occupation: Administrator
Marital Status: Single
Patient History:
• Past history: asthma, hypertension, cholecystectomy, ankle fracture, depression, non-smoker
• Medications: ramipril - 2.5mg daily, paroxetine - 20mg daily, fluticasone 250 – 2 puffs daily,
Ventolin (salbutamol) - 2 puffs if required
• Allergies: nil

10/9/14
History: 2-day history of runny nose, cough productive of yellow sputum, slight fever, wheezy,
but not short of breath. Asthma usually well-controlled on preventer (fluticasone 250 - 2 puffs daily)
Examination: Temperature 37.5, pulse 82, BP 120/80, respiratory rate 12, obvious nasal congestion,
throat red, ears normal, no increased work of breathing, no accessory muscle use, chest scattered
wheeze, no crepitations.
Assessment:
1. Viral upper respiratory tract infection
2. Infective exacerbation of asthma
Treatment:
Ventolin 2 puffs 4-hrly, continue preventer
Medical certificate for work
Review as required

12/9/14
History: Increasing shortness of breath & wheeze over last 24hrs, feeling feverish at times, minimal
yellowy sputum, short of breath on minimal exertion.
Examination: Temperature 38, pulse 95, BP 120/80, respiratory rate 16, throat red, ears normal,
mildly increased work of breathing, chest - widespread wheeze, no crepitations.
Assessment
Infective exacerbation of asthma - symptoms worse.
Treatment:
Amoxicillin 500mg 3x daily, prednisolone 25mg daily x3 days
Continue 4-hrly Ventolin & preventer

13/9/14
10.30am
History: More short of breath today despite prednisolone & antibiotics. Feeling feverish & unwell.
Examination: Short of breath at rest, respiratory rate 25, obvious accessory muscle use & increased
work of breathing, pulse 112, BP 100/65, temp 37.7, chest exam - widespread wheeze, bibasal
crepitations.
Assessment: Acute asthma, ?pneumonia.
Treatment: Ventolin Nebules (salbutamol) 5mg, review.

10.45am No improvement. Still obvious respiratory distress

Refer to Emergency Department for acute management & investigation ?pneumonia

Writing Task:
Using the information given in the case notes, write a letter of referral to the Admitting Officer at
the Emergency Department, Newtown Hospital.

In your answer:
• Expand the relevant notes into complete sentences
• Do om use note form
• Use letter format

The body of the letter should be approximately 180-200 words.

Admitting Officer
Emergency Department
Newtown Hospital

13.09.2014

Dear Sir/ Madam,

Re: Ms. Sally McConville, aged 38

Thank you for seeing Ms. McConville, a single administrator asthmatic patient who has presented
with clinical manifestations of acute asthma with a probable pneumonia. Your urgent management
would be highly appreciated.

Ms. McConville is an asthmatic patient, for which she is on fluticasone and salbutamol. However, she
does not have any known allergies.

On 10.09.2014, Ms. McConville attended the clinic with a complaint of a viral upper respiratory tract
infection which had been present for 2 days. Plus, it was associated with infective exacerbation of
asthma which was treated accordingly with Ventolin and fluticasone.

Two days later, Ms. McConville presented with complaints of shortness of breath and a wheeze,
which had been present over the last 24 hours. On examination, there was a deterioration of her
medical condition because there had been a mildly increased work of breathing with a widespread
wheeze over the chest. Accordingly, Amoxicillin, 500mg three times daily, and prednisolone, 25mg
three times daily, were prescribed.

On today’s visit, 13.09.2014 at 10:30am, Ms. McConville’s shortness of breath became worse despite
taking her medications. On general examination, there has been shortness of breath at rest, an
increased respiratory rate, an obvious accessory muscle use and an increased work of breathing
while on chest examination, there has been a widespread wheeze with bibasal crepitations. Based
on the above, she has been diagnosed with acute asthma with probable pneumonia. As a result, she
was given Ventolin nebules. After 15 minutes, there has been no improvement, because of which
she is being referred urgently into your care.

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

Yours sincerely,
Doctor
TIME ALLOWED: READING TIME: 5 MINUTES October 2014
WRITING TIME: 40 MINUTES

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

notes:

You are a doctor at Bayview Medical Clinic. You are assessing a 22-year-old man who has worsening
asthma.

PATIENT DETAILS:
Name: Mr Zach Foster
DOB: 25/10/91 (Age 22)
Address: 77 Creek Road, Bayview

Medical history:
Asthma, since age 3 - problematic at times, 2 previous hospital admissions (most recent - 3 years ago)
Eczema
Smoker - 4 years, 10-20/day

Allergies: Cats and Hay fever

Medications:
Ventolin prn
Pulmicort 200mcg one puff bd

Family history: Sister (age 18) - asthma

Social history: Builder, single

Presenting complaint: For last 3/52 (3wks):

- SOB - when playing sport.
- Wheeze & cough - waking Pt at night.
- 1' use of Ventolin for symptoms.
Treatment Record
11.10.14
Subjective:
Preventative inhaler (Pulmicort): compliance unclear; claims to use inhaler some of the time.
Burning sensation in lower part of chest after meals - consistent with
gastro-oesophageal reflux disease (GORD).

Objective:
Chest clear.
Peak flow 500Umin.
Abdomen lax & non-tender.

Tests: CXR, FBE

Diagnosis: Unstable asthma, possible trigger GORD

Treatment:
• Ensure compliance with Pulmicort.
• Trial of pantoprazole (PPI) for GORD.
• Discussion about smoking cessation.Writing
• Review 1/52.

18.10.14
Review:
Still smoking.
Non-compliant with Pulmicort - forgets to take it.
PPI - effective, nil side effects.
Test results:
CXR - clear
FBE - normal
Treatment:
• Use pantoprazole for another 7/52 (7wks) then review.
• Discussion about Pulmicort missed dosage - take as soon as remember, then back to normal, do
not double dose.
• Advice on smoking cessation (e.g., nicotine patch, information brochures, support groups, etc.).
• Continue current management; refer to respiratory specialist for lung function & advice about Rx.
• Review appointment 7/52.
Writing Task:
Using the information given in the case notes, write a letter of referral to Dr Williams, a
respiratory specialist, for further management of Mr Foster's asthma. Address the letter to Dr
Tanya Williams, Respiratory Specialist, Bayview Private Hospital, 81 Canyon Road, Bayview.

In your answer:
 Expand the relevant notes into complete sentences
 Do not use note form
 Use letter format

The body of the letter should be approximately 180-200 words.

Dr. Tanya Williams
Respiratory Specialist
Bayview Private Hospital
81 Canyon Road
Bayview
18/10/14
Dear Dr. Williams,
Re: Mr. Zach Foster, DOB: 25/10/91
I am writing this letter to refer Mr. Foster, a 22-year-old builder whose features are suggestive of
unstable asthma, possibly triggered by GORD.
Mr. Foster is a smoker and had a medical history of asthma since he was 3 years old, for which he
takes Pulmicort and Ventolin. Moreover, he is allergic to cats and has hay fever.
On 11/10/14, the patient attended my clinic complaining of exercise induced SOB, nocturnal
wheezing and cough plus increased usage of Ventolin. Additionally, he reported having heartburn
after meals. Please note, the patient was unsure of his adherence to the asthma treatment plan as
he used Pulmicort preventative inhaler only occasionally. Therefore, the importance of following the
treatment plan for his asthma and smoking cessation was discussed. In addition, he was managed
with pantoprazole for his GORD and CXR plus FBE were ordered.
Luckily, today, his CXR and FBE were normal and the patient reported that PPIs were effective,
therefore, he was advised to take them for another 7 weeks. However, the patient forgot to take
Pulmicort and failed to stop smoking; thus, he was counseled about missed doses of Pulmicort,
nicotine patches and joining a support group for smoking cessation.

In light of the above, I am referring this patient for a lung function test and advice on his asthma
management.
For further queries, please do not hesitate to contact me.

Yours sincerely,

Doctor
Word Count: 218 words
Dr. Tanya Williams
Respiratory Specialist
Bayview Private Hospital
81 Canyon Road
Bayview

18.10.2014
Dear Dr. Williams,
Re: Mr. Zach Foster, DOB 25.10.1991

Thank you for seeing Mr. Foster, a 22-year-old patient, who has been suffering from unstable
asthma. Your further assessment would be highly appreciated.

Mr. Foster is a single builder. He is smoker although he has been asthmatic since he was three years
old, and he has a positive family history of asthma. In addition, he has eczema as well as cats and hay
fever allergies. Kindly note that he is currently on Pulmicort 200mcg, one puff twice daily, and
Ventolin, when needed.

On 11.10.2014, Mr. Foster attended the clinic with clinical manifestations which were consistent
with gastro-oesophageal reflux disease (GORD) with unclear compliance of Pulmicort. As a result, a
chest X-ray and a full blood count had been ordered and he was diagnosed with unstable asthma,
possibly due to GORD; for which, pantoprazole was prescribed. Therefore, I advised him to stop
smoking and to be compliant to his medications.

On today’s visit, Mr. Foster presented for the follow-up, and unfortunately, he is still a smoker.
Furthermore, he was not compliant to Pulmicort, however he was taking Pentazole regularly which
was effective in alleviating the GORD symptoms. Therefore, Pentazole was recommended for further
seven weeks. Additionally, a plan about how to take Pulmicort missed dosage was discussed, and
smoking cessation was discussed again.

Based on the above, Mr. Foster is being referred into your care for a lung function test and advice
regarding his asthma management. Should be any queries, please do not hesitate to contact me.

Yours sincerely,

Doctor
Dr. Tanya William
Respiratory Specialist
Bay view Private Hospital
31 Canyon Road
Bay view

18th October 2014

Dear Dr. William,

Re: Mr. Zach Foster, D.O.B: 25th October 1991

Thank you for seeing Mr. Foster, a 22-year-old single builder, who has features of worsening
bronchial asthma.

Mr. Foster has been treated for bronchial asthma for 3 years with 2 previous hospital admissions. His
medical records reveal that he has been smoking for 4 years and suffers from eczema. Please note
that he has allergy to cats and has hay fever.

Initially, Mr. Foster came to me, complaining of a burning sensation in his chest, which increased
after meals. On assessment, his chest was clear with a peak of 500 L/min. Therefore, he was
diagnosed with unstable-asthma which was triggered by GORD. Consequently, he was advised to
stop smoking and Pantoprazel was added.

Today, 18.10.2014, Mr Foster presented to the clinic when he had acknowledged a good effect of
Pantoprazl, but he, unfortunately, did not stop smoking, and he was missing doses of his Pulmicort
inhaler. Thus, my decision was to continue the same treatment and I offered him treatment options
to help him give up smoking. Furthermore, a CXZ had been arranged which showed a clear chest.

Based on the above data, I am referring Mr. Foster for further management as I believe he needs
respiratory function tests. Please, contact me for any queries.

Yours sincerely,

Doctor
TIME ALLOWED: READING TIME: 5 MINUTES November 2014
WRITING TIME: 40 MINUTES

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

notes:
Patient Name: Dolores Hoffmann (Ms)
Patient History:
DOB 22.06.1986
Allergic to penicillin.

Social History:
Single woman - no family in Australia; lives with long-term boyfriend.
Sales assistant- ladieswear in a department store.

11 December 2013: At pub last night with friend. 2 glasses wine + several cocktails. Then fainted
5-10mins unconscious and vomited once. No Hx fits/seizure's/incontinence.
No symptoms gastroenteritis or URTI. Work very busy/stressful. Feels ''woozy"
today. No appetite. Requested check-up.
OE: slightly pale; T 36°, P 72 reg, BP 120/70, medical certificate (Med. Cert.)
- 1 day, rest, watch for new symptoms.
Blood tests (FBE, LFT, U&E): normal

7 August 2014 Skin check. Several moles Land R neck - ok. Advised to monitor for changes.

2 September 2014 URTI since 2/52, yellow-green sputum; SOB, tight chest, wheezy; lethargic.
Smoker.
Anxious re. EBV (Epstein-Bar virus) - work colleague is off with it.
Reassurance.
Rec. rest. Med. Cert. given for 2 days.
Ordered bloods.
7 September 2014
HAEMATOLOGY:
Haemoglobin 124g/L (115-165)
ABC 4.8 x 1012/L (3.80-5.50 X 1012/L)
PCV 0.37 (0.35-0.47)
MCV 88 fl (78-99)
MCH 30 pg (27-32)
White Cell Count 7.0 X 109/L (4.0-11.0 X 109/L)
Neutrophils 8.8 X 109/L (2.0-8.0 X 109/L)
Lymphocytes 2.8 X 109/L (1.0-4.0 x 109/L)
Monocytes 0.4 X 109/L (< 1.0 x 109/L)
Eosinophils 0.3 X 109/L ( < 0.6 X 109/L)
Basophils 0.0 X 109/L (< 0.2 x 109/L)
Platelets 250 X 109/L {150-450 x 109/L)

Paul Bunnell/latex screening test for IM (infectious mononucleosis): negative

Rx: erythromycin 250mg qid

22 November 2014
Orofacial HSV-1 for 3 days. Rx: aciclovir 200mg - 4hrly for five days+ topical acicolvir 3% - qid.
Job stress+++ causing depression, nightmares, insomnia, difficulty getting up, loss of appetite, low
libido.
Poor memory and concentration; loss of pleasure; loss of confidence.
Low tolerance for alcohol.
Split up with boyfriend. Now living alone. Considering quitting job. Wants a break from working.
Recommended referral to psychiatrist - Pt resistant.
Rx: temazepam 20mg - 30mins before bed
R/V: 1 week

29 November 2014
Diagnosis: reactive depression and anxiety
Pt has not filled temazepam script - not keen on drug Rx.
Pt has agreed to a referral to psychiatrist.
Writing Task:
Using the information in the case notes, write a letter of referral to Dr John McLennan,
psychiatrist, Royal Mental Health Clinic, 177 Park Avenue, Newtown.

In your answer:
• Expand the relevant notes into complete sentences
• Do om use note form
• Use letter format

The body of the letter should be approximately 180-200 words.

Dr John McLennan
Psychiatrist
Royal Mental Health Clinic
177 Park Avenue
Newtown

29/11/2014

Dear Dr McLennan,

Re: Ms Dolores Hoffmann, D.O.B:22/06/1986

Thank you for seeing Ms Hoffman, a 28-year-old sales assistant, whose features are consistent with
reactive depression and anxiety .

Ms Hoffmann is single and lives alone in Australia.

On25/04/2014, initially, Ms Hoffmann complained of wooziness and stress at work. Additionally, the
earlier night, she fainted at a pub after taking several cocktails. Nine-months later, she presented
with features which were consistent with upper respiratory tract infection, upon which,
erythromycin was prescribed. She suspected having contracted Epstein bar virus as her colleague.

One -month later, she presented with depressed mood, nightmares, insomnia, loss of appetite
and poor libido. Moreover, she had poor memory, poor concentration, loss of pleasure ,loss of
confidence. Unfortunately ,she split up with her boy. In addition, she was considering quitting her
job. Consequently, Temazepam was prescribed .

Today, Ms Hoffmann reported poor compliance with Temazepam regime. However, she accepted
to be seen by psychiatrist. ·

In view of the above, I am referring her for further assessment and management. For any queries,
please feel free to contact me.

Yours sincerely,

Doctor
Dr John McLennan
Psychiatrist
Royal Mental Health Clinic
177 Park Avenu
Newtown

29/11/2014

Dear Dr McLennan,
Re: Ms. Dolores Hoffman, D.O.B.: 22/06/1986

Thank you for seeing Ms. Hoffman, a 28-year-old patient, whose features are suggestive of
depression and anxiety. Your further assessment and management would be highly appreciated.

Ms. Hoffman is a single sales assistant who has recently broken up with her boyfriend and lives
alone. Please note, she is also a smoker, and is allergic to penicillin.
On 2/9/2014, Ms. Hoffman presented with symptoms of URTI and was worried about the possibility
of having infectious mononucleosis. Nevertheless, the ordered blood tests were unremarkable. Last
week, she presented with orofacial HSV, for which systemic and topical acyclovir were prescribed.
After further discussions, she informed me of the recent split-up with her boyfriend and the
increased stress she was having at her work, which made her consider quitting from her work.
Moreover, she complained of having several depressive symptoms including: nightmares, insomnia,
loss of appetite and libido, along with poor memory and concentration. At that time, temazepam
was commenced.

On today’s review, with no improving regarding her symptoms, she reported that she had not been
taking temazepam; as she had not been interested in taking medications. However, she agreed to be
referred to a psychiatrist although she refused this idea a week before.
In view of the above, my diagnosis at that point is reactive depression and anxiety. Therefore, I am
referring her to you for your careful assessment and treatment. For more queries, please contact me.

Yours sincerely,

Doctor
Dr John McLennan
Psychiatrist
Royal Mental Health Clinic
177 Park Avenu
Newtown

29/11/2014

Dear Dr McLennan,
Re: Ms. Dolores Hoffman, D.O.B.: 22/06/1986

Thank you for seeing Ms. Hoffman, a 28-year-old sales assistant, whose features are suggestive of
reactive depression and anxiety. Your further management would be highly appreciated.

Ms. Hoffman is a single woman, has no family in Australia; however, she used to live with her
boyfriend before splitting up with him. Regarding her past medial history, she experienced a single
fainting attack as a result of excessive alcohol consumption and she informed me that this had
happened due to the pressure of her stressful busy work. A month later, she presented with moles
on the left and right neck; therefore I advised her to observe these moles for any other skin changes
that might develop.

On 22.11.14, Ms. Hoffman presented to the clinic reporting an increase in her work stress; therefore,
she started complaining of symptoms of depression and anxiety, which are as follows: nightmares,
insomnia, difficulty getting up, loss of appetite and loss of libido. Additionally, she has been suffering
from poor memory and concentration, loss of pleasure and loss of confidence. Kindly note, she
considered quitting her job. As a result, she was prescribed temazepam, and was recommended to
be referred to a psychiatrist; however, she refused.

On today’s visit, Ms. Hoffman has been diagnosed with reactive depression and anxiety.
Furthermore, she was not keen on taking her medication; however, she agreed to be referred into
your care.

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

Yours sincerely,
Doctor
Dr. John McLennan
Psychiatrist
Royal Mental Clinic
177 Park Avenue
Newtown

29/11/14

Dear Dr. McLennan

Re: Ms. Dolores Hoffmann, DOB: 22/06/1986

I am writing this letter to refer Ms. Hoffmann, a 28-year-old female whose features are suggestive of
reactive depression and anxiety.

Ms. Hoffmann is a single sales assistant who lives alone and has no family members in Australia.
Moreover, she is allergic to penicillin.

On 11/12/13, the patient attended my clinic complaining of light-headedness, decreased appetite and
stress from work. Therefore, a general check-up was done which showed no abnormalities on examination
and blood tests; thus, she was advised to rest. After 9 months, she presented complaining of typical
symptoms of URTI and was managed accordingly. On the same visit, she reported having anxiety as her
co-worker was diagnosed with EBV infection; therefore, blood tests were done to reassure the patient
which came negative. Please note, at that time, she was living with her boyfriend.

On 22/11/14, she visited my clinic complaining of work related stress, depression, insomnia, poor memory
and loss of libido. In addition, she stated that her relationship with her boyfriend ended and currently, she
lives alone. Consequently, temazepam was commenced after she refused to be referred to a psychiatrist.

Today, the patient accepted to be referred to a psychiatrist and told that she never started the prescribed
drug.

In view of the above, I am referring this patient for your further management.

Yours sincerely

Doctor

Word Count: 216 words

Writing Recall 2015
1 /2015 = Write a letter of referral to: Endocrinologist, for further management and
assessment of a man who has diagnosed with type 2 diabetes mellitus.

2 /2015 = Write a letter of referral to: Gastroenterologist, requesting his advice on

diagnosis and assessment of, a 25-year-old male whose features are suggestive of IBD.

3 /2015 = Write a letter of referral to: Local Doctor, update him about condition of his a
women pt following her a right total knee replacement surgery and discharge from rehab.

4 /2015 = Write a letter of referral to: Memory Center, for full memory assessment and
diagnosis of a women who has complaining of dementia.

5 /2015 = write a letter to: Referral Local Doctor, update him about a meningitic patient’s
status and follow-up treatment that may require in future.

6/2015 = Write a letter of referral to: Occupational Therapist, detailing him about a
patient status and requesting workplace assessment of a man with sever low back strain.

7 /2015 = Write a letter of referral to: Psychiatrist, for urgent assessment and
management of a man who has complaining of severe depression and bipolar disorder.

8 /2015 = Write a letter of referral to: Chest surgeon, for follow-up investigations and
assessment to a women whose features are suggestive of bronchogenic carcinoma. .

9 /2015 = Write a letter of referral to: The ER cardiologist, for urgent assessment and
management of a man whose features are suggestive of unstable angina.

10 /2014 = Write a letter of referral to: Orthopedics surgeon, for further assessment and
management of a man who has complaining of worsening OA.
TIME ALLOWED: READING TIME: 5 MINUTES January 2015
WRITING TIME: 40 MINUTES
Dr. Grantley Cross
Endocrinologist
City Hospital
Suite 32
55 Main Road
Newtown

24/1/15

Dear Dr. Cross,

Re: Mr. Brett Collister, DOB: 20/11/1970

I am writing this letter to refer Mr. Collister, a 45-year-old male whose features are suggestive of
type 2 diabetes mellitus.

Mr. Collister is married with four children. Moreover, he has no known history or allergies.

On 26/10/14, the patient attended my clinic complaining of a painful right knee. His examination was
unremarkable except for a high BMI (30); thus, he was advised to lose weight and to exercise. After
two months, he presented complaining off fatigue, soreness in his eyes and dizziness for the previous
three to four weeks. Furthermore, his lifestyle remained the same and his weight did not change
significantly compared to his previous visit. As a result, blood tests were ordered.

Unfortunately, today, the patient was still feeling tired, and he reported having vision problems.
Additionally, his tests showed elevated levels of random and fasting glucose as well as
HbA1c, which was 8.5%, whereas his lipid levels were all elevated including HDL.

In light of the above, I am referring him for your further management and assessment. For any
quires, please do not hesitate to contact me.

Yours sincerely,

Doctor

Word length 182

Dr. Grantley Cross
Endocrinologist
City Hospital
Suite 32
55 Main Road
Newtown

24/1/15

Dear Dr. Cross,

Re: Mr. Brett Collister, DOB: 20/11/1970

Thank you for seeing this patient, a 45-year-old factory foreman, whose features are suggestive of
diabetes mellitus type 2, for your assessment and further management.

Mr. Collister is married and has three children.

During the last few months, Mr. Collister has been presenting to my clinic frequently. The first and
second visit was due to sore throat for which he took amoxicillin and fluids. Because of pain in his left
and right shoulder, he visited me again. In addition, he felt fatigued and stressed at that time:
therefore, an analgesic was prescribed; moreover, I advised him to reduce weight, increase his daily
exercises and I referred him to a physiotherapist as well as to be reviewed in a three months.

On 04/01/2015, he was still having fatigability with sore eyes and dizziness. Moreover, he did not
change his lifestyle in terms of diet and exercise; therefore, he was still overweight. Investigations
including cholesterol and blood sugar levels were ordered.

On 24/01/2015, he presented with complaints of decreased vision, sore eye and fatigability. His
examination was normal apart from high BMI. However, random and fasting glucose levels were 13.5
and 7.4 mmol/L respectively along with elevated HDL/LDL.

In view of the above, your assessment and further management would be highly appreciated.
For any queries, please do not hesitate to contact me

Yours sincerely,

Doctor X
Dr Grantly Cross
Endocrinology Consultant
City Hospital
Suite 2z
55 Mile Main Road
Newtown

24th January 2015

Dear Dr. Cross,

Re: Mr. Brett Collister, D.O.B: 20.11.1970

Thank you for seeing Mr. Collister, a 45-year-old factory fareman, who has features of type 2 DM.

Mr. Collister has been a patient of mine for a long time. He is married with 3 children. His medical
reports reveal that he is an overweight gentleman and he had an attack of infectious mononucleosis
in 2003.

At first, Mr. Collister came to me on 22.03.2014, complaining of chest infection which was treated
symptomatically. One month later, he attended with another attack of chest infection which
responded well to amoxicillin.

Over the last 3 months, Mr. Collister has presented many times with right knee and left shoulder pain.
Consequently, he was referred to a physiotherapist after he had been advised to lose weight and to
do exercises. However, he did not change his lifestyle and he was reluctant to lose weight.

On 04.01.2015, he attended with a complaint being tired and dizzy. Therefore, some blood tests
were arranged. Twenty days later, he came for the tests' results which were disappointing, as they
showed high blood sugar and cholesterol.

Based on the above data, my provisional diagnosis is type 2 DM. I am referring him to you for
further treatment. Please, contact me for more queries.

Yours sincerely,

Doctor
Dr. Grantley Cross
Consultant Endocrinologist
City Hospital
Suite 32
55 Main Road
Newtown

24.01.15

Dear Dr. Cross,

Re: Mr. Brett Collister, DOB 20.11.1970

Thank you for seeing Mr. Collister, a 45-year-old factory foreman, who has been complaining of signs
and symptoms suggestive of diabetes mellitus type 2. Your further management would be highly
appreciated.

Mr. Collister is married, and has 3 children. He is overweight because there is no adjustment to diet
or exercise; however, he is interested in watching football, playing darts and fishing. Please be noted,
he has a non-significant past medical history and there are no known allergies.

On 04.01.15, Mr. Collister presented complaining of a 4-week history of tiredness and sore eyes that
have been associated sometimes with dizziness and this was suspected to be due to orthostatic
hypotension. Therefore, I ordered blood tests to review his cholesterol level and his blood sugar level.

On today’s visit, Mr. Collister attended the clinic with the same complaints; furthermore, he reported
some deterioration in his vision. Unfortunately, the results of his investigation revealed an increase
in all the blood sugar levels including the random glucose, the fasting glucose and the glycosylated
hemoglobin. Regarding the blood lipid profile, there were increase in all of the cholesterol, LDL and
triglyceride levels.

Based on the above information, Mr. Collister has been diagnosed with diabetes mellitus type 2 and
being referred into your care for further assessment. Should be any queries, please do not hesitate
to contact me.

Yours sincerely,
Doctor
Dr Grantley Cross
Consultant Endocrinologist
City Hospital
Suite 52
55 Main Road
Newtown

24.01.2015

Dear Dr Cross,

RE: Brett Collister, D.O.B: 20.11.1970

Thank you for seeing Mr Collister who has been presenting with tiredness and dizziness over the past
few months. Your further assessment and management wound be highly appreciated.

Or
I am writing to refer Mr. Collister, a 45 -year- old factory foreman, who has been recently diagnosed
provisionally with diabetes. Your further management would be highly appreciated.

Or
I am writing to refer Mr. Collister, a 45 -year- old factory foreman, whose features are suggestive of
type 2 diabetes mellitus. Your further management would be appreciated.

Mr Collister, who works as a factory foreman, is a 45-year-old married man, and has 3 children.
Kindly note that he has been a regular patient of mine for ten months.

Initially, he attended the clinic with uncomplicated upper respiratory tract infection which responded
well on amoxicillin. Plus, he had a rotator cuff tear and osteoarthritic knee pain, which were treated
with both pain killers and a life style modification. Then, review, after 3 months for further
assessment, was arranged.

On 04.01.2015, when Mr Collister came to the clinic, he reported that he had been feeling dizzy,
run down and had had sore eyes for 3 weeks. Although he was previously advised to modify his life
style, he did not follow the instructions and his weight became above the average. Accordingly, some
important blood tests were ordered, and he was asked to come for review when the results come out.

On review, unfortunately, his condition did not improve. Moreover, his investigations revealed that
his random and fasting blood sugar were significantly high. Furthermore, his cholesterol level was
above the average, which was consistent with type two diabetes mellitus.

At this stage, specialist advice was recommended. If you need any further information, do not
hesitate to contact me.

Yours sincerely,

Doctor.
TIME ALLOWED: READING TIME: 5 MINUTES February 2015
WRITING TIME: 40 MINUTES

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

notes:
Mr Patrick Newton (born on 6 July 1989) is a patient in your General Practice.

Patient details:

Name: Mr Patrick Newton

Residence: 10 Ashwood Street, Stillwater

Social background: 25-year-old accountant, single, lives with parents

21 Feb 2015
Subjective
Presenting complaint:
Presentation with 4 month Hx of chronic mild diarrhoea & low-grade intermittent R lower quadrant
abdo pain; lethargy, decrease appetite, decrease weight (3kg in 4 months)

Social/family Hx:
Smokes 10-15 cigarettes per day
Regular squash player
Uncle has Crohn's disease
increase Anxiety and embarrassment relating to symptoms and impact on social participation:
- dietary modification unsuccessful in alleviating symptoms
- recently stopped attending Friday evening squash matches with work colleagues
- has not sought medical advice (has attempted to self-manage illness by diet and OTC pain relief)

Past medical Hx: 6 month Hx low-grade intermittent joint pain in R & L wrists

Medications:
OTC Ibuprofen 200-400mg, 3 or 4 times a day (as required)
No known allergies
Objective
T - 36.4°C; P - BO (regular); Ht-175cm; Wt- 79kg
Abdomen - generalized tenderness, no HSmegaly (enlargement of liver and spleen)
Cardiovascular & resp examination - normal
Urinalysis - normal
FBE increase WCC 11 .1x109/L , decrease RCC 4.0x1012/L
decrease Hb 125g/L
Faecal occult blood test - positive
Mildly elevated CRP (13mg/L) and ESR (14mm/hr)

Assessment:
?Inflammatory bowel disease (IBD)
?Crohn's disease/ulcerative colitis (UC)
No urgent systemic signs

Plan:
Advise on smoking cessation
Counsel on IBD & likely investigations
Refer to gastroenterologist for diagnosis & assessment

Writing Task:
Using the information given in the case notes, write a letter of referral to gastroenterologist, Dr
Jack Thomas, seeking his advice on diagnosis and assessment. Address the letter to: Dr Jack
Thomas, Department of Gastroenterology, City Hospital, Main Road, Stillwater.

In your answer:
• Expand the relevant notes into complete sentences
• Do om use note form
• Use letter format

The body of the letter should be approximately 180-200 words.

Dear Dr. Jack Thomas
Gastroenterologist
City Hospital
Main Road
Still Water

12/02/15

Dear Dr. Thomas,

Re: Mr. Patrick Newton, DOB: 06/07/1989

I am writing this letter to refer Mr. Newton, a 25-year-old male whose features are suggestive of
inflammatory bowel disease.

Mr. Newton is a single accountant who smokes and has a family history of Crohn's disease in his uncle.

On today's visit, the patient attended my clinic complaining of a four-month history of chronic
diarrhea, intermittent right lower quadrant abdominal pain and fatigue. Additionally, he reported a
decreased appetite which was evident by the three kilograms lost in the same period. Furthermore,
he has had intermittent pain in his right and left joints for the last 6 months. His examination was
unremarkable except for tenderness in his abdomen. As a result, blood tests were ordered which
showed elevated levels of WBC and decreased RCC plus Hb. Moreover, FOBE was positive and his CRP
and ESR levels were also elevated. Therefore, the patient was counseled about his smoking habits
and inflammatory bowel disease.

In light of the above, I am referring this patient for your further management and assessment. For
any quires, please do not hesitate to contact me.

Yours sincerely,

Doctor

Word length 178

Dr Jack Thomas
Department of Gastroenterology
City Hospital
Main Road
Stillwater

12.02.2015

Dear Dr Thomas,

Re: Mr Patrick Newton D.O.B: 06.07.1969

I am writing this to refer Mr Newton, a patient of mine, who has been presenting with chronic mild
diarrhoea and lower abdominal pain for about 4 months; which is consistent with irritable bowel
disease. Your assessment and further management would be highly appreciated.

Mr Newton is a 46-year-old heavy smoker who has been working as an accountant for almost 25 years.
His abdominal symptoms put him in many embarrassing situations, which led to tremendous stress
and anxiety. Kindly note that he has a past history of joint pain in his both wrists, nevertheless, he is
a regular squash player; thus, he has been receiving Ibuprofen tablets to control this pain.

When Mr Newton presented to my clinic today, he, over the last four months, has been complaining
of diarrhoea, abdominal pain, lethargy and weight loss. Further, he tried to modify his diet in order
to relieve his symptoms; however, this was unsuccessful. Moreover, he has not seen a doctor in spite
of his dreadful symptoms, believing that these symptoms can be managed by a life style modification
and OTC medications. On examination, he seemed to have no abnormalities, whereas, his fecal
occult blood testing was positive and his CRP was elevated. Accordingly, specialist advice was highly
recommended.

Thank you for seeing Mr Newton. If you need any further information, do not hesitate to contact me.

Yours sincerely,

Doctor
Dr. Jack Thomas
Department of Gastroentrology
City Hospital
Main Road
Stillwater
21.02.2015
Dear Dr. Thomas,
Re: Mr. Patrick Newton, DOB 06.07.1989

Thank you for seeing Mr. Newton, a 25-year-old accountant, who has been complaining of signs and
symptoms suggestive of inflammatory bowel disease. Your further assessment would be highly
appreciated.

Mr. Newton is a smoker. He is single, and he lives with his parents. He is a regular squash player.
Please be noted, his uncle is known to have Crohn’s disease.

On today’s visit, Mr. Newton presented with a 4-month history of chronic mild diarrhea.
Or
On today’s visit, Mr Newton came to the clinic with a complaint of chronic mild diarrhea which had
been present for four months. That complaint has been associated with low-grade intermittent right
lower abdominal pain. In addition, he has complained of lethargy, decreased appetite and decreased
weight for about 3 kg in 4-month duration. Furthermore, his symptoms have had a bad impaction on
his social participation as he stopped attending Friday evening squash matches. He expressed trials to
alleviate symptoms, without seeking medical advice, including dietary modification and using over-
the-counter medications with no improvement. On abdominal examination, there was generalized
tenderness; however, no splenomegaly or hepatomegaly has been noticed. Additionally, the blood
tests revealed an increase in the white cell count, C-reactive protein and the erythrocyte
sedimentation rate while the red cell count and the hemoglobin revealed a decrease plus a positive
faecal occult blood test.

Mr. Newton has been advised to quit smoking and has been diagnosed with possible inflammatory
bowel disease, either Crohn’s disease or ulcerative colitis.

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

Yours sincerely,
Doctor
TIME ALLOWED: READING TIME: 5 MINUTES March 2015
WRITING TIME: 40 MINUTES

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

notes:
Your patient, an 81-year-old woman, recently had a right total knee replacement (R.TKR) on

25/02/2015.
She is being discharged today.
Patient: Ms Betty Johnson
Address: 12 Merry Street, Stillwater
Marital Status: Widowed

Past Medical History:

Aortic valve replacement & pacemaker 2010
Osteoarthritis since 2011 - pain & immobility increase past 3yrs
For R.TKR Feb 2015: full blood work, typing & cross matching, X-rays, ECG etc.

Regular Medication (25/2/15):

Paracetamol 665mg 2 tabs tds
Warfarin 3mg mane - ceased 5 days preoperatively, started Clexane
(enoxaparin sodium - anticoagulant)

Social Background: Widowed 1986. Lives alone. 4 children

Post Op:
25/02/15 11:30am
Returned to ward following R. TKR.
Vital signs- BP 115/70, P 82, R 16, T 36.9°C.
Circulation observation good, knee high on pillow.
Hb 80g/l = IVT Transfusion.
IV cephalothin 1g qid for 24 hours.
Increase regular oral paracetamol (1g qds).
Patient Controlled Analgesia (PCA) - morphine ✓ effective.
Wound - nil ooze.
26/02/15
Wound - good, sponged.
Restart warfarin 5mg today.
sic Clexane 80mg given for anticoagulation.
Cease PCA. Start oxycodone 5 - 10mg pm.
Pathology: FBE, U&Es, Liver Function Tests (LFTs), Hb.
Path results ✓, Hb 100g/l = commence Feratab (iron sulphate) 300mg mane.

27/02/15
sic Clexane 80mg.
Start warfarin 5mg nocte.
Removal of (R/O) dressing, wound good, R/O alt. clips on 03/03/15.

28/02/15
Crutches, short walks. Wound good, afebrile.
sic Clexane 80mg given.

01/03/15
s/c Clexane 80mg given.

02/03/15
X-rays, bloods ✓ , INR - 3.0, Hb 1119/1, ECG - no abnormalities.
Managing w/ min assistance.
Cease Clexane.

03/03/15 - 05/03/15 Wound clean, R/0 alt clips tomorrow. Mobility good. Obs
06/03/15 R/0 remaining clips. Pathology✓. Transfer to rehab today.

Rehab:
07/03/15✓Admission complete - stable. Circ ✓. Mobility, crutches good.

08/03/15 -13/03/15
Mobility, frame use, trial stick, pool, gentle exercises= good. Showering w/ min assistance.
Path & X-ray.
14/03/15
Path ✓, INR - 3.8.
decrease warfarin 4mg nocte, Hb - g/l , decrease Feratab 150mg mane.

15/03/15-19/03/15
Uneventful – gradually increase independence.
Wound good. Obs ✓, Physio exercises good. Home list provided.

21/03/15
✓ ✓ No cardiac issues.
Discharged w/ home nursing assistance (personal hygiene, home care). Wound exposed, shower w/
min assist. Stick/ frame prn.
Discharge medication: warfarin 4mg nocte, Feratab 150mg mane, paracetamol 1g qds, oxycodone 5-
10mg prn.
Rehab appt in 2 weeks.
Advised to see local doctor in 1 week, referral for local doctor - suggest repeat FBE, INR.

Writing Task:
Using the information given in the case notes, write a letter of referral to Ms Johnson's local
doctor, Dr Tony Jones, to update him on her condition following her recent surgery and discharge
from rehab. Address the letter to Dr Tony Jones, Private Practice, 12 New Street, Stillwater.

In your answer:
• Expand the relevant notes into complete sentences
• Do om use note form
• Use letter format

The body of the letter should be approximately 180-200 words.

Dr. Tony Jones
Private Practice
12 New Street
Stillwater
21st March, 2015
Dear Dr. Jones,

Re: Ms. Betty Johnson Age: 81 years

Thank you for seeing Ms. Johnson, an 81-year-old widow who is being discharged following an
uneventful right total knee replacement operation. Your further follow up would be highly
appreciated.

Ms. Johnson, a mother of four children, lives alone. Regarding her past history, she had aortic valve
replacement and pacemaker insertion in 2010. Also, she has been suffering from chronic osteoarthritis
since 2011 which has worsened over the last three years. she takes warfarin which had been replaced
with Clexane 5 days prior to the operation.
On 25/2/15, a right total knee replacement was performed. Her postoperative recovery was
uneventful except for anaemia for which feratab was commenced. After about 12 days, with
progressive recovery she was transferred to a rehabilitation center where, with physiotherapy and
gentle exercises, she had become independent gradually. Please note, on 14/3/15, her warfarin and
feratab doses were adjusted following INR 3.8 and Hb 112g/dl.
Today, she is being discharged with home nursing assistance. Additionally, warfarin, feratab,
paracetamol and oxycodone have been prescribed. Moreover, a rehab review in 2 weeks and review
with a local doctor in 1 week have been advised.

In view of the above, it would be highly appreciated if you could follow up this patient further and
repeat FBE and INR.

Please do not hesitate to contact me if you have any queries.

Yours sincerely,

Doctor

Word length 217

Dr. Tony Jones
Private Practice
12 New Street
Stillwater

21.03.2015

Dear Dr. Jones,

Re: Ms. Betty Johnson, aged 81 years

Ms. Johnson is being discharged from our hospital into your care today after undergoing a right total
knee replacement.

On 25.02.2015 Ms Johnson underwent an R.TKR, and fortunately the operation had been done
without any complications. She started Clexane instead of her current warfarin medication which
had been ceased 5 days preoperatively. She returned to the ward post-operatively while she was
vitally stable; however, her hemoglobin was low hence a blood transfusion transfusion was given to
compensate the blood loss during the surgery. Additionally, she was prescribed an intravenous
Cephalothin.

On subsequent check-ups, Ms. Johnson’s wound was clean and the dressing was removed. She
resumed her warfarin and newly started oxycodone upon request. However, Clexane was ceased.
Her hemoglobin had become better; therefore, she was prescribed Feratab. On 06.03.2015, she was
transferred to the rehabilitation where she started her mobility using a stick together with some
gentle exercises. Subsequently, she showed better independence.

Today, the patient was discharged with a home nursing assistant for personal hygiene and home care.
The discharging medications include: warfarin, Feratab in the morning, paracetamol and oxycodone.
Plus, she was advised to see you in one week and to repeat the FBE and the INR to adjust her
medications.
Should be any queries, please do not hesitate to contact me.

Yours sincerely

Doctor
TIME ALLOWED: READING TIME: 5 MINUTES April 2015
WRITING TIME: 40 MINUTES

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

notes:
Your long-term patient, Mrs Welshman, has attended your GP surgery with her daughter. Both are
concerned about Mrs Welshman's memory.
Patient: Mrs Patricia Welshman (D.O.B.: 28/03/1930)
Address: 24 Kenneth St, Newtown
Marital status: Widowed, 5 adult children
Next of kin: Christine - daughter
Diagnosis: Osteoporosis. Dementia (?early stage Alzheimer's)
Social background: Widowed 40yrs. Lives alone, children within 10km radius.

2007-2013 Regular GP visits to this clinic, Pathology, BP- stable

19 June 2014 Fall - bruised nose only. X-ray- NAO. Will begin to take it easy, slow down.
27 July 2014
Occupational Therapist (OT) home assessment: Evaluated shower rails, ramp. Bed ok. Rev 4-6mths.
Discussed shower with OT. All ok.
Shower every other day to avoid falls.
Community Support: Home care provided by local council, 1/fortnight.

14 December 2014 BP 145/85

Pathology: FBE, U&Es, LFTs - all NAO
Lipids:
Total cholesterol 4.8mmol/L (< 5.5)
HDL cholesterol 1.4mmol/L (0.9-2.2)
LDL cholesterol 2.9mmol/L (< 2.0)
Triglycerides 1.1mmol/L (0.5-2.0)
LDUHDL 2.1 , Chol/HDL 3.4
Vitamin D < 54 (60-160nmol/L)

Discussions: Spare scripts - ?not filling them or taking medication regularly.

Assures me she is taking medication regularly.
Suggested Webster pack (a folder used to store medication on a weekly basis), reluctant, promised to
adhere to medication regime.
Rev 2 months, post-pathology.
13 February 2015
Pathology: FBE, U&Es, LFTs - all NAO
Lipids: Total cholesterol 5.3 mmol/L ( < 5.5)
HDL cholesterol 1.3mmol/L (0.9-2.2)
LDL cholesterol 3.5mmol/L (< 2.0)
Triglycerides 1.2mmol/L (0.5-2.0)
LDL/HDL2.7 , Chol/HDL 4.1 , Vitamin D < 20 (60-160nmol/L)
Discussions: BP 130/80 ✓ encouraged.

19 April 2015
Vit D low , LDL high agreed to use Webster pack.
Rev 2 months, post-pathology.
BP 130/70, Vit ✓ & Lipids ✓
Medication sorted.
Daughter with Pt, both want to discuss memory issues.
Poor memory noted++, e.g., forgetting hair dresser, dinner engagements, missing
social events. Behavioural changes, decision-making issues. Family concerned.
Mini memory assessment:
Poor short-term memory, day & date - several attempts, no result. 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 - high amyloids in brain)
and dementia (symptom). Alzheimer's - common cause of dementia.
More assessments before diagnosis. Referred to Memory Clinic.
Rev, post-assessment.

Writing Task:
Using the information given in the case notes, write a letter of referral to Dr Jones at the Newton
Memory Clinic, 400 Rail Rd, Newtown, to provide him with your brief assessment and request full
memory assessment and diagnosis.
In your answer:
• Expand the relevant notes into complete sentences
• Do om use note form
• Use letter format
The body of the letter should be approximately 180-200 words.
Dr. Jones
Newton Memory Clinic
400 Rail Road
Newtown

19/04/2015

Dear Dr. Jones,

Re: Mrs. Patricia Welshman, DOB: 28/03/1930

I am writing this letter to refer Mrs. Welshman, an 85-year-old widowed woman who is suffering from
a poor short-term memory.

Mrs. Welshman has been my patient for the past eight years. She lives alone and has five adult
children. In terms of her medical records, she is a known case of osteoporosis and dementia which
have been managed accordingly. Moreover, she has a family history of Alzheimer's disease.

On 14/12/2014, the patient attended my clinic for a regular check-up. At that visit, spare prescriptions
were noticed which demonstrated that she had not been taking the medications regularly; thus, she
was advised to use a Webster pack.

On today's visit, the patient, accompanied by her daughter, visited my clinic concerned about her
memory issues as she was forgetting dinner engagements and social events. In addition, behavioral
changes and decision-making issues were reported. On her mini memory assessment, she was unable
to recall days, dates and months even after several attempts.

In light of the above, I am referring Mrs. Welshman for a full memory assessment and diagnosis.
For any queries, please do not hesitate to contact me.

Yours sincerely,

Doctor

Word length 186

Dr. Jones
Newtown Memory Clinic
400 Rail Rd
Newtown

19.04.2015

Dear Dr. Jones,

Re: Mrs. Patricia Welshman, D.O.B: 28.03.1930

I am writing to refer Mrs. Welshman who has features suggestive of an early stage of Alzheimer’s disease.
Your assessment would be highly appreciated.

Mrs. Welshman is an 85-year-old widow who lives alone despite having five adult children. Kindly note that
she has a family history of Alzheimer’s disease. With regard to her medical history, she has been my long-
term patient and she has osteoporosis and dyslipidemia. Therefore, she receives atorvastatin, Vitamin D,
metoprolol and pain killers.

On 14.12.2014, she attended the clinic for a routine review. Her assessment was accepted, apart from
borderline high blood pressure and a deranged lipid profile. Further discussions revealed that she has a
difficulty in remembering medication times. In terms of her home care, the occupational therapist had done
some modifications to let her avoid falls.

On 19.04.2015, Mrs Welshman visited the clinic accompanied by her daughter who was concerned about
Mrs. Welshman’s memory. At that time, the patient’s daughter confirmed many facts about her mother’s
conduct: she forgets hair dresser, dinner engagements and she misses many social events. Moreover, she
was worried about her mother’s behavioural and social changes. On mini memory assessment of Mrs.
Welshman, she was worried, but successfully confirmed the year. However, she could not remember the
date and day.

In view of the above, I am referring her for more assessment regarding her memory. For more queries,
please contact me.

Yours Sincerely,

Doctor,
Dr. Jones
Newtown Memory Clinic
400 Rail Road
Newtown

19.04.2015

Dear Dr. Jones,

Re: Mrs. Patricia Welshman, DOB 28.03.1930

Thank you for seeing Mrs. Welshman, an 85-year-old patient, who has features suggestive of an early stage
of Alzheimer’s disease. Your further assessment would be highly appreciated.

Mrs. Welshman is a widowed mother having 5 children; however, she lives alone. She is a hypertensive and
a dyslipidemic patient on regular medications. Please be noted, she has a family history of Alzheimer’s
disease.

On 14.12.14, Mrs. Welshman’s blood pressure was high and her pathology results revealed an unsatisfactory
lipid profile levels because she was incompliant on her medications and as a result, she was advised to use a
Webster pack to ensure not to forget her medications again; however she was reluctant to use it. Two
months later, there was more deterioration in her pathology results; hence she agreed to use the Webster
pack.

On today’s visit, Mrs. Welshman’s blood pressure and pathology results showed an improvement; however,
both of her and her daughter discussed some memory issues about Mrs Welshman. For more details, she
reported forgetting her hair dresser and dinner engagements as well as missing social events. Moreover,
some behavioral changes and decision-making issues have been noticed. As a result, Mrs Welshman’s family
was concerned about these behavioural changes. Accordingly, a mini-mental examination had been
performed and revealed a poor short-term memory.

Mrs. Welshman, who has been diagnosed with dementia most probably due to Alzheimer’s disease, is being
referred into your care for a full memory assessment and for confirming the diagnosis.

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

Yours sincerely,

Doctor
Dr Jones
Newtown Memory Clinic
400 Rail Road
Newtown

19/04/2015

Dear Dr. Jones,

Re: Mrs. Patricia Welshman, D.O.B: 28/03/1930

I am writing to refer Mrs. Welshman, an 85-year-old lady, whose features are consistent with an early stage
of Alzheimer’s disease. Your further assessment would be highly appreciated.
Mrs. Welshman has been my patient for a while. Although she is a widow and has 5 adult children, she lives
alone. Regarding her medical history, she has osteoporosis and hyperlipidemia; therefore, she takes Lipotor,
Oste-vitD and pain killers. Kindly note that she has a family history of Alzheimer’s disease.

On 14/12/2014, when the patient attended my clinic, apart from hyperlipidemia, low levels of vitamin D and
irregularly taking her medications, she seemed well. I, wherefore, suggested using a Webster pack.

Today, Mrs Welshman presented to my clinic with her daughter who was worried about her mother’s
memory. Her daughter reported that the patient had been forgetting hair dressers, social events and dinner
engagements, for which her family was worried. Moreover, the patient expressed behavioural changes and
was indecisive. A further assessment revealed that the patient was unable to recognize the day and the
date, although she recognized the year correctly.

In view of the above, my provisional diagnosis is an early stage of Alzheimer’s disease; therefore, I am
referring this patient into your care for further assessment of her memory. For any queries, please contact
me

Yours sincerely,

Doctor
TIME ALLOWED: READING TIME: 5 MINUTES May 2015
WRITING TIME: 40 MINUTES
Dr. Lorna Bradbury
Stillwater Medical Clinic
12 Main Street
Stillwater

23rd May 2015

Dear Dr. Bradbury,

Re: Ms. Isabel Garcia DOB: 1/1/1995

I am writing to update you regarding Ms. Garcia, a 20-year-old student who has been treated
successfully for bacterial meningitis. Your further follow up would be highly appreciated.

Ms. Garcia was referred with suspected meningitis for urgent management. At that time, she was
presented with painful stiff joints, headache, neck stiffness, photo-phobia and rash. On examination,
she was afebrile and was unable to touch her chin to chest while lying supine. In addition, petechial
rashes over abdomen and legs along with a bruise on her left arm was found. Therefore, suspecting
meningitis, required blood tests with lumber puncture were ordered.

After receiving blood test results where white cell count and CRP were significantly raised, empirical
antibiotic ceftriaxone with dexamethasone were started with a proper dosage schedule. Moreover,
benzylpenicillin was added when bacterial meningitis was confirmed through lumbar puncture and
culture results. the patient was responded to the treatment, discussion regarding immunization was
had with her family. Furthermore, the services was notified.

In view of the above, the patient needs your further follow-up and it would be highly appreciated
if you could arrange chemoprophylaxis for people in recent close contact along with advice for
seeking urgent medical attention if there any signs of unusual illness.

Yours sincerely,

Doctor

Word length 205

Dr Lorna Bradbury
Stillwater Medical Clinic
12 Main Street
Stillwater

23.05.2015

Dear Dr Bradbury,

RE: Ms Isabel Garcia, D.O.B: 01.01.1995

I am writing update you regarding the condition of Ms Garcia who has been recently treated for
bacterial meningitis. Your further follow up would be highly appreciated.

Initially, Ms Garcia presented to the Emergency Department and reported that she had had painful
stiff joints for about one week, along with headache, neck stiffness and skin rash. Moreover, her
physical examination showed bruises on her left arm and petechial rash over her abdomen; however,
her temperature was normal in spite of her severe illness. Accordingly, some blood tests were
ordered and an urgent lumbar puncture was done.

Unfortunately, the results of the investigations of Ms Garcia illustrated a serious infection with
Neisseria meningitides. To illustrate, her lumber puncture revealed an elevated level of the white
blood cells which was consistent with bacterial meningitis. Therefore, she was given immediately
Ceftriaxone 2g IV injection and Dexamethasone 10 mg. Besides, I discussed with Ms Garcia and her
family the importance of the family members’ immunisation. Kindly note that the Department of
Human services was notified about the patient’s diagnosis.

Furthermore, it is highly recommended to ensure that all of her family members were immunized,
and to encourage the patient’s relatives to seek medical advice if any signs of illness develop.
Additionally, chemoprophylaxis for any person who has been recently in contact with Ms. Garcia is
highly recommended. If you need any further information, do not hesitate to contact me.

Yours sincerely

Doctor
Dr. Lorna Bradbury
General Practitioner
Stillwater Medical Clinic
12 Main Street

23/05/2015

Dear Dr. Bradbury,

Re: Ms. Isabel Garcia D.O.B: 01/01/1995

I am writing this letter to update you regarding the condition of Ms. Garcia who has been recently
treated for bacterial meningitis. Your further care would be highly appreciated.

Initially, on 23/05/2015, Ms. Garcia presented to the Emergency Department with the complaints of
painful stiff joints, sensitivity to light and bruising. Further discussions revealed that she also had
headache, neck stiffness, photophobia and rash. On examination, the patient had bruises on the left
arm, petechial rash on the abdomen and the legs, and was unable to touch her chin to her chest
while she was lying on her back; therefore, specific laboratory tests such as: FBC, C-RP, lumbar
puncture and blood cultures were immediately requested.

Regarding Ms Garcia’s treatment, after the results of the blood tests had been received, which were
diagnostic for Neisseria Meningitides, the following medications were prescribed for the patient:
dexamethasone, ceftriaxone and benzyl penicillin. Fortunately, the patient responded properly to
the treatment. Kindly note that the Department of Human services was notified about the patient’s
diagnosis.

Furthermore, it is highly recommended to ensure that all of her family members were immunized,
and to encourage the patient’s relatives to seek medical advice if any signs of illness develop.
Additionally, chemoprophylaxis for any person who has been recently in contact with Ms. Garcia is
highly recommended. For any queries, please contact me.

Yours sincerely,

Doctor
Dr. Lorna Bradbury
Stillwater Medical Clinic
12 Main Street
Stillwater

23.05.2015

Dear Dr. Bradbury,

Re: Ms. Isabel Garcia, DOB 01.01.1995

I am writing to update you regarding the condition of Ms Garcia who was referred with signs and
symptoms suggestive of bacterial meningitis. Your further care would be highly appreciated.

On 23.05.2015, Ms. Garcia attended the Emergency Department with a complaint of painful stiff
joints which had been present for one week. That complaint was associated with sensitivity to light
and an increase in bruising. Furthermore, she has been suffering from headache, neck stiffness,
photophobia and rash. On examination, there were bruising on her left arm and some petechial
rash on the abdomen and the legs. Additionally, she was unable to touch her chin to her chest
while lying supine. As a result, some investigations have been ordered; including, a full blood count,
a renal function test, a liver function test, a C-reactive protein (CRP), blood cultures and a lumbar
puncture.

Please be noted that the results revealed an increase in both of the white cell count and CRP while
the lumbar puncture showed an elevated white cell count with polymorphonuclear predominance
as well as an elevated protein, while the glucose was decreased. For more confirmation, a subsequent
microscopy and a culture had been ordered, which confirmed the diagnosis of Neisseria meningitis.

As for Ms. Garcia’s treatment, she had received her medications including ceftriaxone 2g intravenous
and dexamethasone 10 mg intravenous while benzylpenicillin was added following the lumbar
puncture results. She responded properly to the treatment. However, her close family members
and friends are in need to be immunized and Ms. Garcia needs to be educated about seeking an
immediate medical attention on observation of any signs of an unexplained illness.

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

Yours sincerely,

Doctor
Dr. Lorna Bradbury
Stillwater Medical Clinic
12 Main Street
Stillwater

23.05.2015

Dear Dr. Bradbury,

Re: Ms. Isabel Garcia, DOB 01.01.1995

Thank you for caring about Ms. Garcia who was referred with signs and symptoms suggestive of
suspected meningitis. Your further follow-up would be highly appreciated.

On 23.05.2015, Ms. Garcia attended the Emergency Department with a complaint of painful stiff
joints which had been present for one week. That complaint was associated with sensitivity to light
and an increase in bruising. Furthermore, she has been suffering from headache, neck stiffness,
photophobia and rash. On examination, there were bruising on her left arm and some petechial
rash on the abdomen and the legs. Additionally, she was unable to touch her chin to her chest while
lying supine. As a result, some investigations have been ordered; including, a full blood count, a renal
function test, a liver function test, a C-reactive protein (CRP), blood cultures and a lumbar puncture.

Please be noted that the results revealed an increase in both of the white cell count and CRP while
the lumbar puncture showed an elevated white cell count with polymorphonuclear predominance
as well as an elevated protein, while the glucose was decreased. For more confirmation,
a subsequent microscopy and a culture had been ordered upon which the diagnosis was confirmed
as Neisseria meningitis.

Ms. Garcia had received her medications including ceftriaxone 2g intravenous and dexamethasone
10mg intravenous while benzylpenicillin 1.8g was added following the lumbar puncture results. She
responded well to the treatment. However, her close family and friends are in need to be immunized
and Ms. Garcia needs to be educated about seeking an immediate medical attention on observation
of any signs of an unexplained illness for which she is being referred back into your care.

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

Yours sincerely,
Doctor
TIME ALLOWED: READING TIME: 5 MINUTES June 2015
WRITING TIME: 40 MINUTES

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

notes:
You are a doctor at Newtown Medical Clinic. Mr Barry Jones is a regular patient of yours.

Patient: Mr Barry Jones

54 Woods Street Newtown
D.O.B. 01 .04.1972 (age 44)

Reason for presenting: Wants to return to work after back injury - employer supportive

Medical history: 1984 - Appendix removed

Family and social history:
Married - Susan Jones, 3 children
Work - drives forklift in a large warehouse (requires prolonged sitting / occasional heavy-lifting)
Current medications:
Naproxen (non-steroidal anti-inflammatory drug)
Carisoprodol (muscle relaxant, blocks pain)

Condition history:
21/03/15
Presentation: Hurt back lifting heavy box off floor at work. 4 days since initial strain.
No rest, pain worsening.
X-ray: No disc problems.

Diagnosis: Lower back strain - severe.

Treatment:
Exercise: walking daily - gradual t time/distance.
Referral to physio.
Prescription: naproxen and carisoprodol.
30 days off work and certificate to give to employer.
To review in 30 days.
18/04/15
Progress: Back: Still sore.
Moving very stiffly.
Physio: Exercises "very painful" but Pt is compliant.
Exercise: Walking up to 10 min per day.
Treatment: Extended time off work - 30 days. To review in 30 days.

19/05/15
Progress: Back: Recovering well - still in pain.
Still moving very stiffly.
Physio: Attending regular appointments.
Exercise: Walking 15-20 mins per day- "very tiring".
Treatment: increase Naproxen dose.
Extended time off work - 30 days. To review in 30 days.

20/06/15
Progress: Back: Recovering well - still in pain.
Moving stiffly but increase ROM.
Pain increase after 20-30 mins of sitting or lying down.
Physio: Still attending appointments.
Exercise: Walking 30 mins per day- "tiring".
Discussions: Pt bored, discouraged, wants to return to work. Restless.
Treatment: Return to work if no lifting & with regular breaks.
Letter to OT requesting assessment of workplace (advise on duties Pt can perform, etc.).

Writing Task:
Using the information in the case notes, write a letter to Ms Jane Graham, an Occupational
Therapist, detailing Mr Jones' situation and requesting an assessment of his workplace. Address
the letter to Ms Jane Graham, Newtown Occupational Therapy, 10 Johnston St, Newtown.

In your answer:
• Expand the relevant notes into complete sentences
• Do om use note form
• Use letter format

The body of the letter should be approximately 180-200 words.

Ms. Jane Graham
Occupational Therapist
Newtown Occupational Therapy
10 Johnston Street
Newtown
20/06/15

Dear Ms. Graham,

Re: Mr. Barry Jones, DOB: 01/04/1972

Thank you for seeing this 44-year-old man, whose features are suggestive of a severe lower back
strain. He is therefore in need of a workplace assessment.

Mr. Jones is married and works as a forklift driver, which requires him to sit for prolonged periods of
time. In addition, he sometimes lifts heavy objects as a part of his job.

On 21/03/15, the patient attended my clinic complaining of lower back pain that he developed after
lifting a heavy box from the ground at work. Consequently, he was advised to rest for a month,
exercise, and to take pain-killers. After one month, he reported that his back was still sore and very
stiff. As a result, he was given another thirty days off work to rest. On 19/05/15, the patient was
recovering well; however, he was still in pain, even after exercising and attending physiotherapy
sessions; thus, his medication dose was increased, and he was given another certificate for time off
work.

On today's visit, he reported that his back was still stiff despite an increase in the range of motion.
Additionally, the patient was bored and wanted to return back to work; therefore, he was advised to
have regular breaks and to not lift any objects while working.

In light of the above, an assessment of Mr. Jones’ workplace is required, as well as advice about
what certain duties he can perform there. For any queries, please do not hesitate to contact me.

Yours sincerely,

Doctor

Word Count: 244 words

Ms. Jane Graham
Newtown Occupational Therapy
10 Johnston Street
Newtown

20.06.2015
Dear Ms. Graham,
Re: Mr. Barry Jones

D.O.B: 01.04.1972

I am writing to request an evaluation of the work place of Mr. Jones who has recently recovered
from back pain. Your kind assessment would be highly acknowledged.
Or
Thank you for assessing Mr. Jones’ work place. Mr. Jones is a 44-year-old driver who has recently
suffered from a lower back strain. Your evaluation of his workplace would be highly appreciated.

Mr. Jones is a 44-year-old married gentleman, and has three children. He works as a forklift driver at
a warehouse, which requires him to sit for a long time and to lift heavy objects occasionally. On
21.03.2015, he presented to my clinic with a complaint of severe back pain following lifting a heavy
box at work. Fortunately, his x-ray showed no disc prolapse; therefore, he was prescribed pain killers
to relieve that pain, and a sick leave was recommended. Plus, over the past three months, he has
visited the clinic many times for review. At that time, he reported a gradual improvement of his

condition. With regard to physiotherapy, he started it directly after the incident. Hence, he
witnessed a good recovery with only residual pain and stiffness.

Today, Mr Johns attended the clinic since/because he got bored as, currently, he is staying home
doing nothing. Consequently, he requested to return to his work. Upon assessment, I figured out
that he can walk for thirty minutes a day. Please note, as Mr Jones is getting better, I have decided
to allow him to go back to his work under some special precautions: he will not be allowed to carry
heavy objects while working, and regular breaks will be taken.
In view of the above, I am writing to you to request an assessment of his workplace. For more
queries, please contact me.
Yours Sincerely,
Doctor
Ms. Jane Graham
Occupational Therapist
Newtown Occupational Therapy
10 Johnston St.
Newtown

20.06.2015

Dear Ms. Graham,

Re: Mr. Barry Jones, DOB 01.04.1972

Thank you for assessing Mr. Jones’ work place. Mr. Jones is a 44-year-old driver who has recently
suffered from a lower back strain. Your evaluation of his workplace would be highly appreciated.

Mr. Johns is married and has 3 children. He drives a forklift at a large warehouse where he is used
to sitting for a lone time lifting heavy objects occasionally.

On 21.03.2015, Mr. Johns presented with a 4-day history of a severe lower back strain following
lifting a heavy box from the ground at work. Therefore, he was treated accordingly, advised to walk
daily with a gradual increase in time and distance, referred to a physiotherapist and was given 30
days off work. One month later, his leave was extended to another 30 days due to the persistence
of his symptoms. However, after another month, although he started to recover properly, his leave
was extended to another 30 days to ensure his ability to get back to work.

On today’s visit, Mr. Johns attended with some pain and stiff movements; however, there was an
increase in his range of movement. Moreover, he got bored and showed his willingness to return
to work. Accordingly, returning to work has been permitted unless there would not be lifting heavy
objects. There would be regular breaks for him.
Should be any queries, please do not hesitate to contact me.

Yours sincerely,

Doctor
TIME ALLOWED: READING TIME: 5 MINUTES July 2015
WRITING TIME: 40 MINUTES

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

notes:
Mrs Katherine Walter is a patient in your general practice.
History:
Name: Mrs Katherine Walter
DOB: 26 November, 1975
Height:170cm
Asthma- since childhood; budesonide (Pulmicort) inhaler, since 28/06/99
Chronic fungal skin infections (both feet) - currently clotrimazole (Canesten)
Moderate family Hx depression (father, sister, aunt, uncle)
Married; two children (8 & 11 yrs)
Home duties
No hobbies or sport
Family (parents, husband's parents & siblings) live in other states
19/11/14
Subjective:
Here for 'check-up'. Seems well, happy, volunteers at her children's school.
Reports feeling tired. Asthma controlled, more attacks this year. Fungus on feet flares up periodically
- Pt reports no creams seem effective. Overweight.
Examination:
BP-110/95
Heart rate - 76 bpm
Breast check - no palpable mass found
Skin check - no suspicious lesions found
Wt-82kg = BMl-28.4
Tests: Pap smear and CBC
Assessment: Pt appears well. Needs to decrease weight, increase exercise.
Monitor BMl/fitness/lifestyle.

Plan:
Advise Pt re lifestyle changes to decrease weight, increase exercise. Pt to phone for test results
in 1 wk. Recommend miconazole (Daktarin) for fungus. R/v appt 3 mths to assess fungal infection,
weight and fitness.
28/05/15
Subjective:
R/v. Pt reports feeling well and energetic. Too busy to come to scheduled r/v 3 mth - didn't think it
was necessary. Asthma flared up about two months ago but no attacks since then. Fungus improved.
Reports 1'involvement with school (now president of parents' association). Has lost weight, joined
gym (trains daily).

Examination:
BP-108/90
Heart rate - 66 bpm
Wt-69.5kg
BMl-24
CBC-all results in normal range (results of test 19/11/14)
Pap smear - no abnormalities found (results of test 19/11/14)

25/07/15
Subjective:
Reports feelings of not coping and of wanting to die. Feels tired, but sleeps badly. No energy to
complete household tasks, e.g., cooking and cleaning, looking after children.
Feels overwhelmed with responsibilities. Doesn't want to eat. ..

Examination:
BP-120/90
Heart rate - 78 bpm
Wt-50kg
BMl-17.3
Temp - 37.SoC

Assessment:
Depression - severe / ?bipolar disorder. Requires urgent treatment.

Plan:
Refer to psychiatrist for urgent assessment and treatment for depression/ bipolar disorder and
suicidal thoughts. Contact husband to discuss child care, household maintenance, etc.
Writing Task:
Using the information in the case notes, write a letter of referral to the psychiatrist, Dr M Jones, 23
Sandy Road, South Seatown.

In your answer:
• Expand the relevant notes into complete sentences
• Do om use note form
• Use letter format

The body of the letter should be approximately 180-200 words.

Dear Dr. M Jones
Psychiatrist
23 Sandy Road
South Seatown

25/07/15

Dear Dr. Jones,

Re: Mrs. Katherine Walter, DOB: 26/11/1975

I am writing this letter to refer Mrs. Walter, a 39-year-old housewife whose features are suggestive
of severe depression and bipolar disorder.

Mrs. Walter is married with 2 children and has a medical history of asthma which has been managed
accordingly. Additionally, she has a family history of depression.

On 19/11/14, the patient attended my clinic for a general check-up. At that time, she looked happy
and well. Her examination was unremarkable except for a high BMI (28.4); thus, she was advised to
lose weight and to exercise. After six months, on her second visit, she stated that she was feeling
more energetic especially after her participation at her children's school as the president of the
parents' association. In addition, she followed a healthier lifestyle as evidenced by a decrease in her
BMI to 24.

Unfortunately, on today's visit, the patient reported that she had suicidal thoughts and felt
overwhelmed by responsibilities in addition to having no energy to do household chores.
Furthermore, her appetite declined significantly as her BMI was decreased to 17.

In light of the above, I am referring her for your urgent assessment and management. Please note,
her husband contacted to discuss child care.

For any quires, please do not hesitate to contact me.

Yours sincerely,

Doctor
Word Count: 206 words
Dr. M Jones
Psychiatrist
23 Sandy road
South Seatown

25-07-2015

Dear Dr. Jones,

Re: Mrs. Katherine Walter, D.O.B: 26.11.1975

Thank you for seeing Mrs. Walter who has features of depression. Your further management would
be highly appreciated.

Mrs. Walter is a 40-year-old married lady, and has 2 children. Her past medical history is remarkable
for chronic feet fungal infection and asthma; hence, she takes Clotrimazole cream and Pulmicort
inhaler. Please note that she has a strong family history of depression.

On 19.11.2014, Mrs Walter came to my clinic for a check-up when she reported a feeling of
tiredness. Upon examination, she was overweight, and she had a flare up of her feet infection;
therefore, she was advised to lose weight and miconazole was prescribed. After 6 months, she
presented to me when she reported that she had been feeling well and energetic. Moreover, she
acknowledged her involvement in her children-school-activities. Surprisingly, she lost weight after
she had joined a gym.

Today, Mrs Walter came back to me after a month of her last visit as she had experienced dramatic
changes regarding her life. To illustrate, she reported that she had not been able to cope up with her
life, which made her unable to sleep well. Further, she had lost her appetite, had felt tired and had
had a strong desire to die. On examination, she extensively lost more weight.

In view of the above, I am referring her to you for urgent management and to respond seriously to
her suicidal thought. Please, contact me for more queries.

Yours sincerely,

Doctor
Dr. M Jones
23 Sandy Road
South Seatown

25.07.15

Dear Dr. Jones,

Re: Mrs. Katherine Walter, DOB: 26.11.1975

Thank you for seeing Mrs. Walter, a 39-year-old housewife, whose features are suggestive of severe
depression with possibility of bipolar disorder. Your urgent evaluation and management would be
highly appreciated.

Mrs. Walter is patient following in my general practice. She is married and has two children;
however, her extended family lives in other states. Her past medical history is remarkable for
chronic feet fungal infection and asthma; hence, she takes Clotrimazole cream and Pulmicort
inhaler. She has no particular hobbies and does not practice sports. Moreover, she has a family
history of depression to four members of her family.

On today’s visit, Mrs. Walter reported that she had not been able to cope up with her life and that
she had been overwhelmed with responsibilities. In further details, she has been complaining of
sleeping badly although she was feeling tired and unenergetic. Plus, she could not complete the
household tasks. Furthermore, she does not want to eat and expressed her wish as she has suicidal
thoughts. On examination, there was no abnormality detected.

My provisional diagnosis is severe depression with possibility of bipolar disorder which requires
urgent treatment. Kindly note, I contacted her husband and child care and household maintenance
have been discussed.

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

Yours sincerely,

Doctor
TIME ALLOWED: READING TIME: 5 MINUTES August 2015
WRITING TIME: 40 MINUTES

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

notes:
Mrs Mary Clarke (born on 17 September 1960) is a patient in your General Practice.
Patient details
Name: Mrs Mary Clarke
Address: 26 Marine Drive Riverside
Social background:
54-year-old office clerk
Married, lives at home with husband and 20-year-old son
Smokes 30-35 cigarettes per day (>30 yrs)
Family/medical history:
Mother died 66 y.o. - laryngeal carcinoma
Father (coal miner) died 54 y.o. - mining-related lung disease
Nil medication
No known allergies

04.07.15
Patient presented with sore throat, body aches, fever and cough.
Prescription: Augmentin (penicillin)

22.08.15
Presenting complaint:
7-week Hx of dry non-productive cough (no haemoptysis)
Cough commenced with flu-like symptoms , cleared with Augmentin
Associated mild shortness of breath (esp. at night) and "strange sensation of heaviness" in chest
Nil fever, night sweats or rigors
Exercise tolerance OK - chores, shopping, could walk up 2 sets of stairs
Examination: T: 36.7°C, P: 80 regular, Ht: 165cm, Wt: 68kg
Respiratory exam - signs of consolidation associated with monophonic wheeze in R mid-zone
No cyanosis/dyspnoea/ascites
No hoarse voice/Homer's syndrome
No cervical lymphadenopathy
No hepatosplenomegaly/bone pain
Systems review- GIT & CV normal
Sputum cytology - normal
Chest X-ray and CT - R middle lobe atelectasis, enlarged R hilum

Assessment: ?Bronchogenic carcinoma

Plan: Counselled on potential diagnosis and need for further investigations

Refer to thoracic surgeon for follow-up investigations (bronchoscopy, biopsy) and assessment

Writing Task:
Using the information given in the case notes, write a letter of referral to the thoracic surgeon, Dr
Penny Clifton, seeking follow-up investigations and assessment. Address the letter to: Dr Penny
Clifton, Department of Cardiothoracic Surgery, Central Hospital, Main Street, Stillwater.

In your answer:
• Expand the relevant notes into complete sentences
• Do om use note form
• Use letter format

The body of the letter should be approximately 180-200 words.

Dr. Penny Clifton
Thoracic Surgeon
Central Hospital
Main Road
Stillwater

22/08/15

Dear Dr. Clifton,

Re: Mrs. Mary Clarke, DOB: 17/09/1960

I am writing this letter to refer Mrs. Clarke, a 54-year-old woman whose features are suggestive of
bronchogenic carcinoma.

Mrs. Clarke is a married office clerk who has a history of smoking 30-35 cigarettes per day for more
than thirty years. Regarding her family history, her mother died due to laryngeal cancer and her
father also died due to a mining-related lung disease. Please note, she has no known history of
allergies.

On 04/07/15, the patient attended my clinic complaining of sore throat, fever and cough which was
managed with Augmentin antibiotic.

On today's visit, she reported having a 7-week history of non-productive cough, SOB and heaviness
in chest, and I again prescribed Augmentin. Her examination was unremarkable except for signs of
consolidation and wheezing in the right lung. As a result, sputum cytology was ordered which
showed normal findings. Additionally, chest X-ray and CT scan were done, which unfortunately
revealed a right middle lobe atelectasis with enlarged right hilum.

In light of the above, I am referring this patient for follow-up investigations and assessment,
particularly bronchoscopy and biopsy.
For any queries, please do not hesitate to contact me.

Yours sincerely,

Doctor
Word Count: 189 words
Dr. Penny Clifton
Thoracic Surgeon
Central Hospital
Main Road
Stillwater

22/08/15

Dear Dr. Clifton,

Re: Mrs. Mary Clarke, DOB: 17/09/1960

Thank you for seeing Mrs. Clarke, a 54-year old married old office Clarke who has demonstrated
features of bronchogenic carcinoma.
Regarding her social and medical history, Mrs. Clarke lives with her husband and son. her mother
was diagnosed laryngeal carcinoma and died at age of 54 and her father also died at age of 59 due to
lung disease. Please note, she is a heavy smoker since 30 years, but has not taken any medication
and has not a known allergy.

Initially , On 04/07/15, the patient presented complaining of sore throat, body aches, fever and
cough. therefore, oral Augmentin was commenced.

On today’s consultation , Mrs. Clarke reported the cough related to flu illness was cleared.
Furthermore, she complaining a dry cough for 7 weeks. additionally, there was mild shortness of
breathing associated with heaviness sensation in chest. However, there was not a hemoptysis ,fever ,
night sweeting or exercise intolerance. On examination, signs of consolidation accompanied by
wheezing over right lung was detected; Furthermore, right middle lobe atelectasis was revealed by
chest CT scan.

In view of the above, I am referring this patient for a bronchoscopy and biopsy. If you have any
queries, please do not hesitate to contact me.

Yours sincerely,

Doctor

Word Count: 196 words

Dr. Penny Clifton
Department of Cardiothoracic Surgery
Central Hospital
Main Street
Stillwater

22.08.15

Dear Dr. Clifton,

Re: Mrs. Mary Clarke, DOB: 17.09.1960

Thank you for seeing Mrs. Clarke, a 55-year-old office clerk, who has been suffering from features
suggestive of bronchogenic carcinoma. Your further assessment would be highly appreciated.

Mrs. Clarke is married and lives with her husband and son. She has unknown allergies; however, she
has been a heavy smoker for more than thirty years. Furthermore, her mother died at age of 66 with
laryngeal carcinoma and her father died at age of 54 with a mining-related lung disease.

On today’s visit, Mrs. Clarke attended the clinic with a complaint of a non-productive cough which
has been present for seven weeks and has been associated with mild shortness of breath, especially
at night, and a strange sensation of heaviness in her chest. Apart from this, she denied the presence
of fever, night sweats or rigors. Additionally, she reported her proper ability to exercise, do shopping
and to walk up two sets of stairs. On respiratory examination, there were signs of consolidation
associated with a monophonic wheeze in the right middle zone. As a result, investigations were
ordered including sputum cytology, a chest x-ray and a chest computed tomography. The results
revealed normal sputum cytology; however, the chest x-ray and CT scan showed right middle lobe
atelectasis and an enlarged right hilum.

In view of the above, Mrs. Clarke has been diagnosed with possible bronchogenic carcinoma and is
being referred for follow-up investigations including bronchoscopy and biopsy.

For further queries, please do not hesitate to contact me.

Yours sincerely,

Doctor
TIME ALLOWED: READING TIME: 5 MINUTES September 2015
WRITING TIME: 40 MINUTES

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

notes:
Mrs Lucy Clarke is a patient in your General Practice.
Patient details
Name: Mrs Lucy Clarke
DOB: 11 March 1951
Residence: 23 Mountain Drive Coast City
Social background: 64-year-old retired office clerk
Independent, lives at home with husband
Non-smoker, social drinker

20.09.15
Presenting complaint:
1 week history central crushing chest pain on exertion (3x, <15 mins duration)
Associated dyspnoea, radiation of pain down L arm
Relieved by rest
No palpitations, no orthopnoea (difficulty breathing on lying down), no paroxysmal
nocturnal dyspnoea (difficulty breathing at night)
Pt anxious - believes had a "heart attack"

Past medical history:

2001 - diabetes mellitus (OM) Type II (currently stable)
2003 - hyperlipidaemia
2005 - hypertension (HT)

Medications:
Sitagliptin (Januvia) 100mg per oral (p.o.) mane
Insulin (NovoMix30) 25 units subcutaneously (s.c.) b.d.
Atorvastatin (Lipitor) 40mg p.o. mane
lrbesartan (Avapro) 75mg p.o. mane

Family history: Mother - acute myocardial infarction (Ml) at 57 y.o.; died of ischaemic stroke at 59 y.o.
Examination:
T - 36.7°C, P - 80 regular, Ht- 164cm, Wt - 65kg
No peripheral oedema
Systems review - normal
Resting ECG - normal

Provisional diagnosis: Unstable angina

Plan:
Hospital admission for urgent assessment
Referral to Emergency Department cardiologist for update & further management
Counsel patient - advised on serious risk of Ml

Writing Task:
Using the information in the case notes, write a letter of referral to the Emergency Department
cardiologist, Dr Smith. Address the letter to: Dr David Smith, Cardiologist, Emergency Department,
Main Hospital, Coast City.

In your answer:
• Expand the relevant notes into complete sentences
• Do om use note form
• Use letter format

The body of the letter should be approximately 180-200 words.

Dr. David Smith
Cardiologist
Emergency
Department
Main Hospital
Coast City

20/9/2015

Dear Dr. Smith,

Re: Mrs. Lucy Clarke, DOB: 11/03/1951

I am writing this letter to refer Mrs. Clarke, a 63-year-old retired office clerk whose features are
suggestive of unstable angina.

Mrs. Clarke has a significant medical history of diabetes mellitus, hypertension and hyperlipidemia
for which she is taking insulin and lipid lowering drugs. Moreover, though she is a non-smoker,
she is a social drinker. In terms of her family medical records, her mother had a heart attack and
died due to ischemic stroke.

Unfortunately, today, the patient attended my clinic complaining of a 1-week history of a typical
chest pain that happens on exertion and lasts for less than 15 minutes. Additionally, she reported
having difficulty breathing and radiation of the pain to the left arm. However, her symptoms were
relieved by rest. Her examination and ECG were unremarkable. Please note, the patient was
counseled about the increased risk of having an MI.

Taking into account of her history, I believe that this could be a case of unstable angina.
Therefore, I am referring her for your urgent assessment and management . For any queries,
please do not hesitate to contact me.

Yours sincerely,

Doctor

Word Count: 170 words

Dr David Smith
Cardiologist
Emergency Department
Main Hospital
Coast City

20.09.2015

Dear Dr Smith,

RE: Mrs Lucy Clarke D.O.B: 11.03.1951

I am writing this letter to urgently refer Mrs Clarke, a patient of mine, who has been presenting with
central crushing chest pain over the past week. Your immediate assessment and urgent
management would be highly appreciated.

Mrs Clarke, who lives with her husband, is a 64-year-old retired lady. She has a past history of
diabetes mellitus which is controlled by insulin and sitagliptin. Moreover, she suffers from
hypertension and hyperlipidaemia as well, for which she takes irbesartan and atorvastatin,
respectively. Please note that Mrs Clarke’s mother had acute myocardial infarction at the age of 57;
and she died of an ischaemic stroke 2 years later.

Today, when Mrs Clarke presented to the clinic, her chest pain was severe and central. She reported
that her pain had been usually triggered by exertion and relieved by rest. Additionally, it was
associated with shortness of breath and radiating to the left arm, whereas, she denied having any
palpitations or orthopnoea. Although her symptoms were severe, her physical examination and
resting ECG revealed no abnormalities. Accordingly, hospital admission and urgent assessment were
highly required.

In view of the above, I believe, Mrs Clarke has unstable angina. Should be any queries, do not
hesitate to contact me.

Yours sincerely,

Doctor
Dr. David Smith
Cardiologist
Emergency Department
Main Hospital
Coast City

20.09.15

Dear Dr. Smith,

Re: Mrs. Lucy Clarke, DOB: 11.03.1951

Thank you for seeing Mrs. Clarke, a 64-year-old office clerk, whose features are suggestive of
unstable angina. Your urgent assessment would be highly appreciated.

Mrs. Clarke is a married independent woman who lives with her husband. She is a non-smoker;
however, she is a social drinker. Kindly note, she has had diabetes mellitus type II since 2001,
hyperlipidemia since 2003 and hypertension since 2005 and has been treated accordingly.
Moreover, her mother was diagnosed with acute myocardial infarction at the age of 57 and died of
an ischaemic stroke at age of 59.

On today’s visit, Mrs. Clarke presented with a one week history of three episodes of severe
exertional central chest pain radiating down to the left arm, each one of them has lasted for less
than 15 minutes. They have been associated with dyspnea and relieved by rest. However, she denied
the presence of palpitations, orthopnoea or paroxysmal nocturnal dyspnea. As a result, an
examination and a resting electrocardiogram (ECG) have been done, and revealed no abnormality.

Unfortunately, Mrs. Clarke has been diagnosed with unstable angina. Therefore, she was informed
about the serious risk of myocardial infarction and is being referred into your care to be hospitalized
for an urgent evaluation.

For further queries, please do not hesitate to contact me.

Yours sincerely,

Doctor
Dr. David Smith
Cardiologist
Emergency department
Main Hospital
Coast City

20.09.2015

Dear Dr. Smith

Re: Mrs. Lucy Clarke, D.O.B: 11.03.1951

I am writing to refer Mrs. Smith, a 69-year-old office clerk, who has symptoms of acute coronary
syndrome. Your urgent management would be highly acknowledged.

Mrs. Smith is a married lady who lives with her husband. Despite drinking socially, she is a non-
smoker.

Today, 20.09.2015, Mrs Smith came to my clinic complaining of central crushing chest pain which
was exertional, radiating to her left arm, and it was associated with dyspnea. Taking this into
account, she was extremely irritated and concerned about her condition. With regard to her risk
factors, she has had type II DM since 2001, hyperlipidemia since 2003 and hypertension since 2005.
Therefore, she has been receiving sitagliptin, Insulin, Atorvastatin and Irbesartan. Please note that
she has a family history of ischemic vascular diseases as her mother had acute myocardial infarction
and her father died of an ischemic stroke at the age of 59.

My provisional diagnosis is unstable angina despite the presence of normal resting ECG. Hence, she
was counseled and advised on the serious risk of myocardial infarction.

Thank you for your urgent intervention to save her heart. For more queries, please do not hesitate
to contact me.

Yours Sincerely

Doctor
Dr. David Smith
Cardiologist
Emergency
Department
Main Hospital
Coast City

20/09/15

Dear Doctor,

Re: Lucy Clarke

DOB: 11/03/1951

I am writing to refer Mrs. Clarke, a 64-year old married office retired Clarke who is suffering from
crushing chest pain . Your further assessment and management is highly appreciated .
Regarding her social and medical history, Mrs. Clarke lives with her husband and is a non-smoker
and socially drinker. She has had NIDDM , hyperlipidemia and hypertension since 2001,2003 and
2005 respectively. Therefore, she has been taking sitagliptin ,Insulin ,atorvastatin and irbesartan .
Please note, her mother was diagnosed MI and died due to ischemic stroke at age of 59.

On today’s consultation, the patient presented to me with a complaint of crushing chest pain which
had been present since one week. Furthermore, the pain has occurred 3 times for less than 15
minutes for each. moreover, it has radiated down to left arm and worsened on excretion and relived
on rest. On examination, systemically ,vitally signs and resting ECG were normal ; Furthermore, the
patient worried and believed she had a heart attack.

In view of the above, Mrs. Clarke has unstable angina with high risk of MI ; therefore, I would
appreciate your urgent admission and further management . please do not hesitate to contact me
for any assistance you require regarding this patient.

Yours sincerely,

Doctor

Word Count: 188 words

TIME ALLOWED: READING TIME: 5 MINUTES October 2015
WRITING TIME: 40 MINUTES

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

notes:
Mrs Maria Santini (born on 08 January 1948) is a patient in your General Practice.
Patient details
Name: Mrs Maria Santini
Residence: 23 High Street Greenville
Social background:
67-year-old widow, two adult children
Lives alone at home, non-smoker, non-drinker

Patient history:
17.10.2015
Subjective:
Presenting complaint
6wk history progressively increase pain R and L knee joints, especially on flexion and extension
4wk history soft lump on back of R knee, restricted joint mobility, mild-moderate persistent pain
decrease Activities of Daily Living (AOL) - stopped accessing local shops and friends within
walking distance, confined to a two-store house but recently has experienced
difficulty in-climbing stairs
increase Depressive symptoms(+ reclusive, + anti-social, + irritability, + agitation)

History of presenting complaint

2003 onset of osteoarthritis (OA)
2008 lumbar laminectomy (L5/S1)
2010 bilateral hip replacement (restored almost full function, eliminated pain & discomfort)

Past medical history:

2000 hypertension (HT), hyperlipidaemia;2003 OA;2006 paroxysmal atrial fibrillation (AF)

Medications: OA- Glucosamine 1500mg daily

AF - Flecainide 200mg daily, Digoxin 250mcg daily
HT - Trandolapril 2mg daily, lndapamide 1.5mg daily
Hyperlipidaemia - Simvastatin 20mg daily
Allergies – nil
Family history: Mother - acute myocardial infarct; ? died bf ischaemic heart disease (IHD)

Objective: T - 36.?°C, P - 80 regular, Ht - 164cm, Wt - 72kg, BP - 130/85

No skin changes, no swelling, no valgus/varus deformity
Concomitant crepitus (crackling sounds when moving joints) in Rand L knee joints on flexion and
extension
Systems review - normal
MRI - degeneration consistent with OA
FBE - normal
LFT-normal
U&E - normal (serum creatinine 145mmol/L)

Assessment Worsening of chronic OA with significant pain ,AoL and signs of depression

Diagnosis: Baker's cyst in A knee joint plus worsening OA

Plan:
Refer to orthopaedic surgeon for assessment and management of OA
? joint steroid injection
Refer to physiotherapist to improve joint mobility
? Living at Home assessment(? District Nurse)

Writing Task:
Using the information given in the case notes, write a letter of referral to the orthopaedic surgeon,
Dr Bronwyn Clarke. Address the letter to: Dr Bronwyn Clarke, Orthopaedic Surgeon, Orthopaedic
Department, Main Hospital, Greenville.

In your answer:
• Expand the relevant notes into complete sentences
• Do om use note form
• Use letter format

The body of the letter should be approximately 180-200 words.

Dr. Bronwyn Clarke
orthopedic Surgeon
orthopedic
Department
Main Hospital
Greenville
17/10/15
Dear Doctor,
Re: Maria Santino
DOB: 08/01/1948
I am writing to refer Mrs. Santini, a 67-year old widow and mother of 2, who is suffering from
worsening chronic bilateral knee osteoarthritis . Your further management is highly appreciated .
Regarding her social and medical history, Mrs. Santini lives alone at home and is a non-smoker and
doesn’t drink alcohol . She has had hypertension ,hyperlipidemia since 2000. and atrial fibrillation
since 2006. Therefore, she has been taking daily flucainide ,digoxin ,trandolapril, indapamide and
simvastatin. Moreover, The patient was diagnosed osteoarthritis in 2003. for which she has been
taking daily glucosamine. Furthermore, lumber laminectomy (L5/S5) and bilateral hip replacement
were performed in 2008 and 2010 respectively. Please note, her mother died due to IHD and MI.

On today’s consultation, the patient presented to me with a complaint of bilateral knee pain which
had been present since six weeks mainly when she flexed or extended the knee. two weeks later, she
reported that there had been a soft lump on back of right knee ; Therefore, the pain has worsened
until joint mobility restricted and Activity of Daily Living was decreased. Furthermore, the patient
suffers from depression. On examination, systemically was normal a apart from crackle sound was
revealed when right or left knee passively moved . degenerative lesion was detected in MRI .

In view of the above, my provisional diagnosis is Backer cyst in right knee plus worsening bilateral
knee osteoarthritis; therefore, I would appreciate your further assessment and management .
please do not hesitate to contact me for any assistance you require regarding this patient.

Yours sincerely,

Doctor

Word Count: 190 words