The Admitting Officer

Emergency Department
Children's Hospital
Newtown

18/01/2014

Dear: Sir/Madam
Re: Joshua Vance DOB: 17/11/2014

I am writing to refer Joshua Vance, a 2‐month‐old male infant, who is presented with mild dehydration
and long‐standing constipation. He needs urgent review regarding dehydration and further investigations of
constipation.

Joshua Vance was a full‐term baby of normal vaginal delivery. His perinatal and neonatal periods were
uneventful. Furthermore, his routine 6‐week baby check was normal, apart from a decreased bowel motions.
The patient reviewed two weeks later, on 13/01/2014. Still, the constipation is there, and the baby starts to Comment [benchmark1]: was
refuse the breastfeeding. On examination, he was hydrated, and his abdominal assessment was reasonable
apart from hard faces on per‐ectal examination. Coloxyl drop was prescribed to him, and his mother advised to Comment [benchmark2]: rectal
give the milk in a bottle mixed with some water.
Comment [benchmark3]: was

Today, the patient brought by his mother for assessment and she complained that he did not pass stool for Comment [benchmark4]: was
five days, refusing feeding and vomits once. However, there is no fever, and he is passing urine normally. On
Comment [benchmark5]: has not passed
assessment, he was mildly dehydrated and irritable. Also, there was a generalised tenderness on his abdomen
but no guarding.

I am referring him to your care for the urgent management of his dehydration. Furthermore, I would
appreciate if you do further investigations regarding his constipation. Comment [benchmark6]: could

Yours sincerely,
Doctor

Report
Word length 205
Comments Mistakes mainly pertain to wrong tense and
passive voice sentence structures. However, the
flow of information is logical and relevant case
notes have been covered. Overall, the letter meets
the expectations.
Grade B
Advice 1. Need to review the rules for passive voice.
2. Always proofread the letter after finishing it.

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