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
