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 [Link] 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 [Link], who is suffering from an acute left ventricular failure and requires
admission to your Cardiology Unit in order to stabilise his condition.
[Link] 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, [Link] 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, [Link] 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 Recalls
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 [Link], 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 [Link]
• 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 ([Link]) 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 [Link] 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 [Link], 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 - [Link]

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