Dr Elvina Sterinberg

Gynecologist
123 Church Street
Richmond 321
6th 06 April 2024
Dear Dr Sterinberg,
Re: Mrs Larissa Zaneeta, Age: 38 years old

Thank you for seeing Mrs Zaneeta, a 38-year-old, marketing manager whose clinical features
are suggestive of secondary infertility. For. She requires your expert advice regarding her
failure to conceive.

Mrs Zaneeta is a marketing manager by profession and has a four-year-old boy. She was
using oral contraceptives before planning for pregnancy
Her husband, also interested for having another child.

In regards to her past medical history, she had been diagnosed with stress-related anxiety due
to work overload and been advised to take sedative medication.
On 11/07/2005, Mrs. Zaneeta initially presented to me with complaints of tiredness, and
insomnia due to work overload for two months. On examination, she looked pale and tired.
She was advised to adopt some relaxation techniques and to reduce working hours. Sleeping
tablets three times a day were prescribed. Please note that she was planning for a second
child in 12 months.

On 15/08/2006, Mrs Zaneeta visited my clinic with similar complaints of insomnia, hectic
working hours and she was unable to conceive despite stopping OCPs for 04 months ago.
wich she had been measured. She was counselled regarding the nature of conception and
was advised to increase frequency of sexual intercourse.

Pap smear and pelvic examination was conducted on 18/01/07 with unremarkable finding.
Furthermore, she was asked to revisit with her husband. Subsequently, on 25/01/07.

Mr Zaneeta found to have was very supportive of having another child with normal erectile
function and a normal libido. finds with. His sperm count was ordered which came out to be
normal today. However, Mrs Zaneeta’s condition remained the same despite having a
normal pap smear and pelvic examination.

It would be rightly highly appreciated if you could further evaluate and give your assess and
manage Mrs Zaneeta’s condition regarding her infertility.

If you have any queries, please do not hesitate to contact me.

Yours sincerely,
Doctor
Corrections
 Purpose paragraph: It's a referral letter, so
elaborate on the medical illness and assessment &
management request accordingly. Do not mention the patient’s personal details in this
paragraph.

 Organization and Layout: For this letter; Introduction > Patient’s personal details > Initial
visit para > Subsequent visits > Today’s visit para > Closing.

 Content: Improve your case note selection by focusing on presenting complaints of the
patient’s most recent visit and by keeping the recipient of the letter and his profession in
mind (to whom you are writing the letter). As this letter is written to a gynaecologist so,
write accordingly following the given pattern and case notes.

 Write the second name of the patient with Mr/Ms instead of the pronoun at the
beginning of each paragraph. If the patient is less than 16 years old, you only write the
first name without Mr/Ms. If pt is over 16 years old, write 2nd name with Mr/Ms ( Mrs.
Zaneeta).

 Elaborate on the closing paragraph according to the patient's requirement and type of
letter as it is a referral letter so, write accordingly.

 Do not write Mr/Ms with the patient’s name in the reference followed by the correct
pattern of writing her age (Re: Mrs Larissa Zaneeta, Age: 38 years old).

 Use the correct pattern of date (On 15/08/2006).

 Some connectors are less suitable for healthcare letter writing. These include
 Academic connectors: furthermore, moreover.
 Informal connectors: besides, meanwhile, apart from that, later on.
 Outdated connectors: hence, thus thereafter.

 Add the closing paragraph before ending the letter (If you have any queries, please do
not hesitate to contact me).

 Genre and Style: Capitalize the correct initials of the medicine’s short form and add the
missing alphabets (OCPs).

 Language: Use the correct form of a verb where required ( and she was unable to
conceive despite stopping OCPs for 04 months ago).
 The underlined lines are written by you but placed
incorrectly. Their underlining refers to the place
where they must be.