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Referral letter – obesity
Notes
Model letter sample 1
Model letter sample 2
Dr D Kurac (name of doctor you are referring the patient to)
SurgeonWeight center (address)393 Victorian RoadRichmond, Melbourne
15 June 2018 (Date – format doesn’t matter)
Dear Dr Kurac (Dear name of doctor.)
Re: Andy Williams, aged 65 years old (Re: patient and age / DOB. If age and DOB are both given, write DOB instead)
Paragraph one: Patient / Condition / Purpose – formats are more or less fixed for all referral letters
Patient – Andy Williams. Condition – obesity. Purpose - Evaulation of obesity and recommendation for treatment (but in paragraph 1, lets keep it brief – evaluation and treatment. We will save the details - Evaulation of obesity, recommendation for treatment for the last paragraph aka request)
I am referring Andy Williams (*Patient), who has been suffering from obesity (*Condition), to you for evaluation and treatment (*Purpose)
I am writing to refer Andy Williams (*Patient) to you. He has been suffering from obesity (*Condition). Your evaluation and treatment (*Purpose) would be highly appreciative.
Thankyou for seeing Andy Williams (*Patient), who has been suffering from obesity (*Condition). for evaluation and treatment (*Purpose)
Paragraph 2
Details: 163 cm, 155.5 kg, BMI 46.6, family history of obesity, medical history (type 2 diabetes, hypertension, sleep apnea, BG levels 100-130 mg/dl, triglycerides 201 mg/dl, serum insulin insulin 19 IU/ml). Medications (30 and 70 units of NPH insulin before breakfast / before or after dinner, 850 mg metformin twice daily, atorvastatin, lisinopril and nifedipine)
Mr Williams has a family history of obesity. He weighs 155.5 kg and his BMI is around 46.6 kg/m2.
He presents with diabetes, hypertension and sleep apnea. Lab reports showed (revealed) that his blood glucose was within 100-130 mg/dl and serum insulin and triglycerides were 19 IU/ml and 201 mg/dl respectively. His medications included 30 and 70 units of NPH insulin before breakfast / before or after dinner, 850 mg metformin twice daily, atorvastatin, lisinopril and nifedipine.
Paragraph 3
Details: Childhood obesity, gains weight every decade, at highest adult weight, participated in commercial and medical weight loss programs, consulted registered dietician,
Mr Williams has been suffering from obesity since he was a child. He participated in various weight loss programs and even consulted a dietician. However, these failed to tackle his obesity problem (failed to reduce his weight to an acceptable range)
*Alternatively, it might be better to combine: family history of obesity, weighs 155.5 kg, childhood obesity together into one paragraph and diabetes / hypertension, lab reports, medications into one paragraph
Paragraph 2
Mr Williams has a family history of obesity. He has been suffering from obesity since childhood. Despite participating in various weight loss programs and consulting a dietician, he continues to put on weight and currently weighs 155.5 kg with a BMI of 46.6 kg / m2.
Paragraph 3
Mr Williams presents with diabetes, hypertension and sleep apnea, for which he is taking 30 and 70 units of NPH insulin before breakfast / before or after dinner, 850 mg metformin twice daily, atorvastatin, lisinopril and nifedipine. Lab reports showed that his blood glucose fell within 100-130 mg/dl and serum insulin and triglycerides were 19 IU/ml and 201 mg/dl respectively.
Paragraph 4 Details: Diet - 3 meals / day. Reports limited fast food consumption 2 nights / weeks,
no alcohol, reports binge eating triggered by stress，plan - Concerned about health / wants to get life
under control, wants to learn about surgical options, partner encouraging.
Mr Williams eats 3 regular meals per day. He limits fast food consumption and doesn’t drink any alcohol. However, he claims (reports / said that) to binge eat occasionally due to stress. He has the support of his partner and is considering surgical treatments that may help him get his weight and general health under control.
Paragraoh 5 - Request: more or less the same format for all referall lettes - In the view of above, kindly evaluate ……
Details - Evaulation of obesity, recommendation for treatment
In the view of above, kindly evaluate Mr William’s condition and suggest him the most appropriate treatment regime. Should you have any questions, please do not hesitate to contact me.
Referral letter – Allergies
Notes
Model letter
Dr Ian RobsonAllergistCentral Hospital Oldtown
17/06/18
Dear Dr Robson
Re: Mr Tom Riddle (DOB: 19/05/08)
Paragraph one
I am referring Mr Riddle, who is presenting with asthmatic symptoms, to you for further testing and identification of his allergies.
Paragraph 2
Details: family history of asthma, childhood asthma – nil episodes 8 years, eczema (periodic), no
known allergies
Mr Riddle has a family history of asthma. He was diagnosed with childhood asthma, which was well controlled for the past 8 years (which didn’t show any symptoms for the past 8 years). He has eczema but no known allergies.
Paragraph 3:
Details:
1/6/18 - 2 weeks breathlessness “needs to sit up”, persistent coughing / wheezing, eyes itching, missing classes. Notes: new accommodation – two cats, dusty old carpet, sleeps on floor
2/6/18 – CXR clear, Pre-bronchodilator – FEV1: 3.61, Post-bronchodilator – FEV1: 4.35, response positive – 20%. Diagnosis: asthma, Plan: oral prednisolone 50 mg – 10 days, albuterol inhaler,
Mr Riddle presented at my clinic on 1/6/18. He complained about breathlessness for 2 weeks, persistent coughing and itchy eyes, which resulted in his absence from college. He also mentioned that he moved into a new accommodation where he had two cats, a dusty old carpet and slept on the floor. In the subsequent visit on 2/6/18 (*Too long winded, we can simply use “1 month later”), Mr Riddle’s Pre-bronchodilator – FEV1: 3.61, Post-bronchodilator – FEV1: 4.35, and response positive – 20% indicated that he had asthma (showed that he was diagnosed with asthma), and for that, I administered him with oral prednisolone (*omit 50 mg – 10 days. Such details aren’t necessary) and albuterol inhaler.
*?? Perhaps it might be alright if I made the following alterations: 1 month later, Mr Riddle’s Pre-bronchodilator and post-bronchodilator values and response positive percentage indicated an asthma episode, which was treated with oral prednisolone and albuterol inhaler.
Paragraph 4
Details: 14/6/18 - sleep disruption, albuterol increased, eczema flare, vitals (BP, pulse, respiratory rate) above normal levels, Oxygen saturation and PaO2 below normal level. Auscultation – bilaterally diminished lung sounds, expiratory wheezing, administered oxygen 3L, attained O2 sat 93%, albuterol hourly, IV corticosteroid – positive response. 17/8/18 – discussed environmental triggers, proper inhaler technique
On 14/6/18, he presented with sleep difficulties and eczema. His blood pressure, pulse respiratory rate were above normal levels, whereas, his oxygen saturation and PaO2 were below normal levels. Auscultations revealed diminished lung sounds and expiratory wheezing. 3L of oxygen, albuterol
(hourly) and IV corticosteroid were administered. 2 months later, I educated him about environmental triggers and proper inhaler technique.
*Alternatively, we can omit details such as: “His vitals such as: blood pressure, pulse respiratory rate were above normal levels, whereas, his oxygen saturation and PaO2 were below normal levels.” Because 3 L of oxygen, albuterol and IV corticosteroid managed to deal with them.
Modified answer: on 14/6/18, he presented with sleep difficulties and eczema. His vitals such as blood pressure, oxygen saturation, were not within normal levels. Diminished lung sounds and expiratory wheezing were heard during auscultation. Oxygen, hourly albuterol and IV corticosteroid were administered. On subsequent visits, I educated him on environmental triggers and proper inhaler technique.
So: Model answer: Twelve days later, he presented again with an acute exacerbation of bronchial asthma that was treated with oxygen, hourly albuterol and intravenous corticosteroids. Subsequent to this visit, he was educated about possible environmental triggers and proper inhaler technique.
Paragraph 5:
Details: further testing and identification of his allergies, provide guidance on environmental management.
In view of the above, kindly conduct the necessary allergenic tests and provide guidance on environmental management. Should you have any questions, please do not hesitate to contact me.
Referral letter – arrhythmia (heart flutter)
Read the cases notes below and complete the writing task which follows:
Time allowed: 40 minutes
Today's Date
08.08.09
Patient HistoryDulcie Wood
DOB 15.07.43
New patient in your General Practice. Moved recently to be near family.
03.07. 09Subjective 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 alcoholCurrent medication: zocor 20mg daily, calcium caltrate 1 dailyNo known allegeries
Objective BP 145/75 P 80 regularHt 160cm Wt 61kgCardiovascular 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.
17.07.09Subjective 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 pmAdvise review in one month.
08.08.09Subjective 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
ObjectiveBP 180/90 P70
Action Contact Dr Raymond’s receptionist and you are able to arrange an appointment for Mrs Wood at 8am on 14/08/09
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 The body of the letter should not be more than 200 words Use correct letter format
Last modified: Tuesday, 12 January 2010, 05:16 PM
Sample Model Letter 3
08/08/09Dr Vincent Raymond422 Wickham TceBrisbane, 4001
Dear Dr Raymond,Re: Dulcie WoodDOB: 15/07/43
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 in 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
Word Length: 191 words
Last modified: Friday, 20 August 2010, 11:26 AM
Referral letter - asthma
Notes
Model letter sample 1
Model letter sample 2
Dr Jan WalkerPulmonologistEpstein Clinic393 Victorian Road
Richmond, Melbourne
2 September 2017
Dear Dr Walker
Re: Susan Forrest (DOB: 19/05/1997) - (Re: patient and age / DOB. If age and DOB are both given, write DOB instead)
Paragraph one: Patient / Condition / Purpose – formats are more or less fixed for all referral letters
I am referring Susan Forrest (*Patient), who has been suffering from asthma (*Condition), to you for assessment and treatment evaluation (*Purpose)
Paragraph 2
Details:
Smoker – 7 years, 10-15/dayFather also has asthmaAsthma since age 4Two previous asthma related hospital admissions, most recent 2015Allergic rhinitis, eczemaSmoking cessation options discussed
Susan Forrest has a family history of asthma and has been suffering from asthma since 4 years old. In addition, she experienced two asthma exacerbations (most recent in 2015) which caused her to become hospitalized. She also presents with allergic rhinitis and eczema. On top of that, she has been smoking around 10-15 cigarettes every day for the past 7 years. Paragraph 3
Details: Current drugs: Ventolin (albuterol), symbicort (budesonide/formoterol) – twice daily, Zyrtec (cetirizine). Non-compliance with preventive inhaler – “forgets”
Currently, she is administered with Ventolin (albuterol), symbicort (budesonide/formoterol) and Zyrtec (cetirizine). She also mentions that she tends to forget to bring her preventive inhaler with her.
*Actually, we don’t have to include that much details on drugs. Simply: Currently, she is administered with Ventolin (albuterol), symbicort and Zyrtec……
Paragraph 4
Details:
25/8/17, short of breath – ongoing, nocturnal cough 7 nights, Ventolin use increase2/9/17 – pulse, temperature, BP within normal limits; CXR clear; FBE clear; PEF 400 L/min
She presented (came to) at my clinic on 25/8/17 complaining about an ongoing shortness of breath, persistent night coughs, and the need to increase Ventolin usage. During her next visit on 2/9/17 (*This is too long winded, use “one week later” instead since 25/8/17 to 2/9/17 is around one week). Her pulse, temperature and blood pressure are all within normal limits, her chest X-ray is clear and her PEF is 400 L/min.
Paragraph 5
Details: assess and evaluate, ? continue with current meds
*Notice that the assessment and evaluation here are pretty brief. It didn’t specify assessment of what? Evaluation of what? Here we can add more details based on our understanding of the case notes.
In the view of above, kindly conduct a thorough (comprehensive) assessment on Susan Forrest’s respiratory condition and a detailed evaluation on the suitability of her current medications (detailed
evaluation if it is advisable for her to continue with her current medications). Should you have any questions, please do not hesitate to contact me.
Referral letter – bowel cancer
Read the cases notes below and complete the writing task that follows
Time allowed: 40 minutes
Today's Date
03.07.09
Patient History Margaret Leon 01 .08. 49
Gender: Female
Regular patient in your General Practice .
14.01.09 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. ClearDoes not smoke or drink
Objective BP 160/90 PR 70 regularHt 152cm Wt 69 kgOn no medication. No known allergies.
Assessment Overweight. Advised on exercise & weight reduction. Borderline hypertension. Review in 3 months
25.04.09
Subjective Feeling better in part due to weight loss
Objective BP 140/85PR 70 regularHt 152cm Wt 61 kg
Assessment Making good progress with weight. Blood pressure within normal range
03.07.09Subjective 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 regularHt 152cm Wt 50 kgCardiovascular and respiratory examination normal.Rectal examination shows no obvious abnormalities.
AssessmentNeed to investigate for bowel cancerRefer 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 The body of the letter should not be more than 200 words Use correct letter format
Last modified: Tuesday, 12 January 2010, 09:08 AM
03/07/2009
Dr. William CarlsonFirst Floor,Ballow Chamber56 Wickham Tce,Brisbane 4001
Dear Doctor Carlson,
Re: Margaret LeonDOB 01/08/1949
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 and as well as that 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 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)
Referral letter – fibroids
Model letter
Paragraph one: patient / condition / request
Patient – Mrs Fielding. Condition – fibroids, request – further investigation and diagnosis
I am writing to refer Mrs Fielding, who is presenting with symptoms suggestive of fibroids, to you for further investigation and diagnosis.
Paragraph two
Details
3/1/19 – very tired, pale, heavy periods for 9 months, passing large clots, change pads and tampons frequently, appetite unchanged
Mrs Fielding first presented to my clinic with her husband on 3/1/19. She appeared pale and fatigue. She complained about heavy periods (menorrhagia suspected) for 9 months, which required her to change pads and tampons very frequently, even during the night. In addition, she observed large blood clots during her periods.
Paragraph three
Details: systemic examination, thyroid, vaginal inspection were unremarkable, speculum: cervix orifice closed, no oozing of blood via orifice, pelvic examination: bulky uterus, no adnexal tenderness or masses
Systemic examination was unremarkable and thyroid tests and vaginal inspection were normal. However, a Pelvic examination found that she has an enlarged uterus.
Paragraph four
Details: provisional diagnosis – fibroids, ordered blood tests: FBC, TFT, coagulation (send to gynecologist once received), pap smear (> 2 years since previous test), transvaginal examination, iron supplement – floradix before meals, stop aspirin intake / change to panadol for pain relief
My provisional diagnosis of Mrs Fielding is fibroids. I have ordered the following blood tests: FBC, TFT and coagulation, for which I instructed Mrs Fielding to forward them to you upon receiving. Mrs Fielding is deal for a pap smear as her last test was more than 2 years ago. I also ordered a transvaginal examination to help identify the cause of her unexplained bleeding.
I prescribed Mrs Fielding with floradix and advised her to stop taking aspirin and consume Panadol instead should she experiences pain.
In the view of above, kindly conduct the necessary investigations to confirm my provisional diagnosis. Should you have any questions, please do not hesitate to contact me,
Referral letter – Gastro-esophageal reflux
Model letter
For case notes like this – with one provisional diagnosis at the very end, we can write the letter this way
Paragraph one
I am writing to refer Ms Hall, who is presenting with symptoms suggestive of Gastro-esophageal reflux, to you for further investigation and diagnosis.
Paragraph two:
Details: father – peptic ulcer, 2004 dyspepsia, 2006 dermatitis; Rx oral and topical corticosteroids
Ms Hall has a history of peptic ulcer. She was diagnosed with dyspepsia in 2004 and dermatitis in 2006, for which she was prescribed oral and topical corticosteroids.
Paragraph three
Details: 18/6/10 – dysphagia (solids), no relapse / remittent course, no sensation of lump, concomitant epigastric pain radiating to back level T12, weight loss: 1-2 kg
Ms Hall presented to my clinic on 18/6/10 with dysphagia of solids which followed a remittent course but didn’t feel any lump in her throat or stomach during swallowing. In addition, she complained about a concomitant epigastric pain which radiated to her back, specifically, at T12. She also experienced weight loss of around 1-2 kg.
Paragraph four
Details: URTI self -mediated with OTC Chinese herbal product – contents unknown, recent increase in coffee consumption, takes aspirin occasionally (2-3 times / month)
Ms Hall self- prescribed an over-the-counter Chinese herbal product with unknown ingredients for her upper respiratory tract infection. She also reported to increase coffee consumption recently. (Recently, she has increased her coffee consumption) Furthermore, she takes aspirin 2-3 times per month.
Paragraph five
Details: non-smoker (since children born), social drinker (mainly sprints), BMI 28.2
Please also note that Ms Hall has stopped smoking for many years, is a social drinker (mainly sprints), and has a BMI of around 28.2.
Paragraph six
Details: further investigation and definitive diagnosis
In the view of above, I am concerned that Ms Hall’s condition will worsen, and it would be highly appreciated if you can conduct further investigations and necessary managements, to confirm my provisional diagnosis (indicate definitive diagnosis)
Or simply
In the view of above, kindly evaluate Ms hall’s condition and conduct the necessary investigations to confirm my provisional diagnosis.
Referral letter – memory loss
Notes
Your long-term patient, Mrs Walshman, has attended your GP surgery with her daughter. Both are concerned about Mrs Walshman’s memory.
Patient: Mrs Patricia Walshman (D.O,B: 10/07/1933)Address: 24 Kenneth St, NewtownMarital status: widowed, 5 adult childrenNext of kin: Christine – daughterDiagnosis: osteoporosis. Dementia (? Early stage Alzheimers)Social background: widowed 40 yrs, lives alone, children within 10 km radiusMedications: osteo vit-D 1000 IU, atorvastatin (lipitor) 20 mg mane, ibuprofen (Bruten) 200 mg prn, metoprolol 100 mg b.d, paracetamol (panadol 500 mg) prn
Past medical history
2010 – 2016 Regular GP visits to this clinic, pathology, BP – stable1 October 2017 Fall – bruised nose only, X-ray – NAD, will begin to take it easy, slow down8 November 2017 Occupational therapist (OT) home assessment. Evaluated shower rails, ramp, bed ok. R/V 4-6
months Discussed shower with OT. All ok Shower every other day to lessen likelihood of falls Community support: home care provided by local council. 1 / fortnight
26 March 2018 BP 145 / 85 FBE: U&E, LFTs – all NAD Total cholesterol 4.8 mmol/l (<5.5) HDL cholesterol 1.4 mmol/l (0.9-2.2) *LDL cholesterol 2.9 mmol/l (<2.0) Triglycerides 1.1 mmol/l (0.5-2.0) LDL/HDL 2:1 Chol/HDL 3:4 *Vitamin D < 54 (60-160 mmol/l)
Discussions: spare scripts – not filling them or not taking medication regularly Assures me she is taking medication regularly Suggested Webster pack (a sealed weekly calender pack designed to help people take their
medication correctly), was reluctant, promised to adhere to medication regime Review 2 months, post-pathology1 August 2018
BP 130/70, vit and lipids within normal range Medication issue resolved
Daughter with pt, both want to discuss memory issues Poor memory noted ++ e.g. forgetting hairdresser appointments, dinner engagements, missing
social events. Behavioral changes, decision making issues
Mini memory assessment: Poor short-term memory, day & date – several attempts, no results. Month – 3 attempts.
Confirmed the year correctly. Quite worried Requested further assessment Family history of Alzheier’s Asked about dementia – explained difference between Alzheimer’s disease and dementia More assessments before diagnosis. Referred Memory clinic R/V post-assessment
Writing task – using the information given in the case notes, write a letter of referral to Dr Jones at the Newtown memory clinic, 400 Rail rd, Newtown, to provide him with your brief assessment and request full memory assessment and diagnosis.
Model letter
Dr Jones (name of doctor you are referring the patient to)Newtown Memory clinic (address)400 Rail RdNewtown
1 August 2018 (Date – format doesn’t matter)
Dear Dr Jones (Dear name of doctor.)
Re: Mrs Patricia Welshman (DOB: 10/07/1933) – (Re: patient and age / DOB. If age and DOB are both given, write DOB instead)
Paragraph 1: patient, condition, purpose. Format is more or less the same
Patient – Mrs Welshman. Condition – memory issues. Purpose – full memory assessment and final diagnosis
I am referring Mrs Welshman, a long-term patient of mine, who is presenting with memory issues, to you for full memory assessment and final diagnosis.
Paragraph 2:
Details:
1 August 2018
Daughter with pt, both want to discuss memory issues Poor memory noted ++ e.g. forgetting hairdresser appointments, dinner engagements, missing
social events. Behavioral changes, decision making issues
Mini memory assessment: Poor short-term memory, day & date – several attempts, no results. 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 and dementia More assessments before diagnosis. Referred Memory clinic R/V post-assessment
Mrs Welshman and her daughter came to my clinic on 1 August 2018 to discuss about Mrs Welshman’s failing memory issues, which were evident in examples such as: forgetting appointments and engagements. In addition, Mrs Welshman demonstrated behavioral changes and experienced decision- making difficulties. I conducted a mini memory assessment and found out that Mrs Welshman was suffering from poor short-term memory as she was unable to remember the day and date of recent events. Mrs Welshman has a family history of Alzheimer. However, more assessments need to be conducted prior to confirming the diagnosis.
Model paragraph
Mrs Welshman and her daughter presented at my clinic to discuss the deteriorating state of her memory. They cited several examples of forgetfulness including missing appointments and perceived changes in her behavior and decision making. Upon conducting a mini memory assessment, the patient’s short term memory was found to be poor and she was unable to recall the day and date. Given that there is a family history of Alzheimer’s disease, Mrs Welshman and her family are clearly anxious and have asked for a more extensive evaluation. Paragraph 3
Details
Hyperlipidemia and Vit D deficiency spare scripts – not filling them or not taking medication regularly Assures me she is taking medication regularly Suggested Webster pack (a sealed weekly calender pack designed to help people take their
medication correctly), was reluctant, promised to adhere to medication regime Review 2 months, post-pathology
In terms of past medical history, Mrs Welshman failed to take her medications for hyperlipidemia and Vitamin D deficiency regularly. Moreover, she had not been filling up spare scripts. Therefore, a Webster pack had to be implemented to help her better manage her medications.
Paragraph 4
Details - request full memory assessment and diagnosis.
*Notice that full memory assessment is detailed enough because it specifies what kind of assessment that should be conducted. However, diagnosis is pretty brief here. Here, we can add other details based on our own understanding of the case notes.
In the view of above, kindly conduct a full memory assessment and other appropriate follow up on Mrs Welshman to confirm the provisional diagnosis. I have arranged Mrs Welshman for another appointment after your assessment. Should you have any questions, please do not hesitate to contact me.
In the view of above, kindly conduct a full memory assessment and other appropriate follow up on Mrs Welshman prior to reaching a final diagnosis (so that a final diagnosis can be made /so as to come up with a final diagnosis). I have arranged Mrs Welshman for another appointment after your assessment. Should you have any questions, please do not hesitate to contact me.
Referral letter - meningitis
Time allowed: 40 minutesRead the case notes below and complete the writing task that follows:
Today’s Date
14.10.10
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 agoNo known allergies
09/10/10
Subjective
Fever, runny nose, mild cough, loss of appetiteUnable to attend school
Objective
Pulse 85/minTemperature 39.4No rashNo neck stiffnessCVS, RS & abdo – normal
Assessment
Viral infection
Management
Keep home from school Rest and paracetamol three times dailyReview in 3 days if no improvement
12/10/10
Subjective
Amina not well Cough +, continuous headache, lethargic, loss of appetiteDifficult to control temperature with ParacetamolMother worried
Objective
Fever 39.8 CNo rash or neck stiffness
Management
Prescribe Brufen 200mg as requiredFBC & UFR were orderedReview in two days with results of reports
14/10/10
Subjective
Both parents very concerned Reported Amina lethargic and listlessVomited twice last night and headaches worse
Objective
FBC- WBC(18000) and left shift Urinary Function Report NormalTemperature 40.2CPulse 110/minMacula-papular rash over legsNeck 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 TaskYou 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 letter:
Expand the relevant case notes into complete sentences. Do not use note form. The body of your letter should be approximately 200 words. Use correct letter format.
Kevin Grove Medical Centre53 Goma RoadKelvin Grove, Brisbane14.10.09
The Duty RegistrarEmergency Paediatric UnitBrisbane General Hospital140 Grange RoadKelvin Grove, QLD, 4222
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, though she and her father understand English.
Initially, accompanied by her parents, she presented to me on 9.10.10 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 IrvingReferral letter – pre-eclampsia
Time allowed: 40 minutesRead the cases notes below and complete the writing task that follows:
Today's Date24/08/10
Patient History
Mrs. Jane MacIntyre (DOB 01.03.71) Two children age 5 and 3Two miscarriagesFirst 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 thrombosisKnown to be heterozygous for Factor V LeidenTreated with prophylactic low molecular weight heparin in two previous pregnanciesNo other medical problemsNot on any regular medicationNegative smear 2007
24/08/10
Subjective
Positive home pregnancy test – fifth pregnancyThinks she is 8 weeks pregnantLast menstrual period 16.1.08Painful urination last three daysRequest referral to the Spirit Mother's Hospital for antenatal care and birth.
Objective
BP:120/80.Weight: 60kgHeight: 165cm Some dysuria for the past 3 days Urine dipstick: 3+ protein, 2+ nitrites, and 1+ bloodAbdomen 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 ageNeeds 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 HospitalCommence her on folic acid 400 micrograms daily, advise to continue until 12 weeks pregnantArrange routine antenatal blood tests – results to be sent to the Spirit Mother's Hospital when receivedCounsel Jane re antenatal screening for Down's Syndrome in view of her ageJane 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 laboratoryPrescribe 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.
Expand the relevant case notes into complete sentences Do not use note form The body of your letter should be approximately 200 words Use correct letter format
Referral letter – prostate cancer
Read the cases notes below and complete the writing task which follows
Time allowed: 40 minutes
Today's Date
15.08.09
Patient History Darren Walker
DOB 05.07.69
Regular patient in your General Practice
09.07. 09Subjective Regular check up, Family man, wife, two sons aged 5 and 3Parents alive - father age 71 diagnosed with prostate cancer 2002.Mother age 68 hypertension diagnosed 1999.Smokes 20 cigarettes per day –trying to give upWorks long hours – no regular exerciseLight drinker 2 –3 beers a week Objective BP 165/90 P 80 regularCardiovascular and respiratory examination normalHeight 173 cm Weight 85kgUrinalysis normal
Plan Advise re weight loss, smoking cessationReview BP in 1 monthRequest PSA test before next visit 14.08.09Subjective Reduced smoking to 10 per dayAttends gym twice a week, Weight 77 kgComplains of discomfort urinating
Objective BP 145/80 P76DRE hardening and enlargement of prostatePSA reading 10
Plan Review BP, smoking reduction in 2 monthsRefer to urologist – possible biopsy prostate
Writing Task
Write a referral letter addressed to Dr. David Booker (Urologist), 259 Wickham Tce, Brisbane 4001. Asl to be informed of the outcome.
In your answer:
* Expand the relevant case notes into complete sentences * Do not use note form * The body of the letter should not be more than 200 words * Use correct letter format
Sample letter
Sample Model Letter 1
15/08/2008
Dr. David Brooker (Urologist)The Urology Department259 Wickham Tce,Brisbane, 4001
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 09/07/09 revealed a strong family history of related illness as 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 14/08/2009, 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 for his condition.
Yours sincerely,
Dr.X
Discharge letter – chest pain and GERD
*Case note is blurry, but most information are irrelevant, so just refer to the details written down
Paragraph one – patient, condition, request
Mrs Henning was presented to the Emergency Department today after experiencing chest pain that
might be attributable to gastro-esophageal reflux. Your follow up care is highly appreciated.
Paragraph two
Details: 6/01/2016 – new onset of chest pain 2-3 episodes, “compression” pain only at night, improved with repositioning (use 2 pillows), recently consuming larger meals at night
Mrs Henning presented with 2-3 bouts of chest pain. She also complained that she felt “compression” pain on her chest at night, which was relieved by repositioning herself using two pillows. In addition, she mentioned that she has been eating larger meals at night recently.
Mrs Henning presented with 2-3 bouts of chest pain. She complained of compression-like chest pain at night, which can only be alleviated by elevating herself with the help of two pillows. She also reported that she has been consuming larger meals at night recently.
Paragraph three
Details: generally thin, vitals such as BP, heart sounds, abdomen sounds are normal
An assessment noted that Mrs Henning is thin. However, her Vitals such as BP, heart sounds, abdomen sounds are normal
Or we can simply put this information in paragraph 2 saying that: Mrs Henning’s physical examination was unremarkable
Paragraph four
Details: provisional diagnosis – chest pain resulting from GERD as only when lying down / not presented with exertion / larger meals at night
Update patient’s GP of recent onset
COPD – continue medications. Follow up with GP in 3-4 weeks. Chest pain – discontinue eating 2-3 hours prior to sleep, follow up with GP in 3-4 weeks – if chest pain continues despite meal adjustment – call GP or visit emergency department. If chest pain begins on trigger – call GP or visit emergency department
My provisional diagnosis of Mrs Henning is chest pain attributable to GERD because her pain is only present when she is lying down or after she has consumed larger meals at night. As you are aware that Mrs Henning has COPD, it is recommended for her to continue with her current medications – albuterol inhalers. Regarding Mrs Henning’s chest pain, it is advisable for her to stop eating 2-3 hours
before sleeping. However, if this chest pain persists or is triggered by exertion, she should consult you or visit the emergency department immediately.
Mrs Henning’s condition is an indicative of chest pain attributable to GERD because her pain is only present either when she is lying down or after eating larger meals at night. The fact that pain doesn’t occur during exertion supports the finding. Since Mrs Henning has COPD, it is recommended for her to adhere to her current medications. Regarding Mrs Henning’s chest pain, it is advisable for her to avoid eating 2-3 hours before sleeping. However, if this chest pain persists or if it is triggered by exertion, she should report it to either yourself or to the emergency department at once.
Discharge letter - Falls
Paragraph: patient / condition / requestMrs Anne Jenkis (*patient) was brought into our emergency department today by an ambulance due
to a fall (*condition) at home this morning. We have some concerns about her general level of self-care and would like you to follow up. (*request)
Paragraph one
Details: fell at home this morning, no injury found, neighbor came to her assistance and called the ambulance, disheveled, unable to get up from the ground by herself, seemed confused, unable to contact her children so left message on daughter’s message bank, neighbor claimed that she had a few recent falls which needed assistance,
Mrs Jenkis fell at home this morning but we couldn’t find any specific injuries. Her neighbor came to her assistance and called the ambulance. When her neighbor found her, she was disheveled and was unable to get up from the ground by herself. Her neighbor also reported that she had a few recent falls requiring assistance. Although she was aware about her surroundings and people, she seemed to be confused about the date and time. (*She also seemed to be suffering from some memory loss) We were unable to contact Mrs Jenkis’s children, so I sent a message to her daughter’s message bank.
Paragraph three
Details: hypertensive, atrial fibrillation, rhonchi heard in lungs, chest x-ray: cardiomegaly leukocytes in urine ward no clinical fractures noted hips lower limbs, hips full range of motion, no shortening / abnormal
rotation of legs, osteoporosis, ambulates without pain healing grazes and bruise elbows,
According to our assessment, we noted that Mrs Jenkin’s had some healing grazes and bruises on her elbows due to her previous falls. X-rays of her hips and legs were normal and she was able to ambulate without any pain. However, she was hypertensive, had atrial fibrillation and cardiomegaly (borderline), and some leukocytes were found in her urine ward.
Paragraph four - request
Details: Discharge plan – letter to GP to follow up: TFTs, digoxin test, MSU, Geri rv, home help / placement
Could you please follow up and act on her TFTs, digoxin levels and MSU results? In addition, would you consider her for a geriatric review? Finally, she may require home help or placement into care. Should you have any questions, please do not hesitate to contact me.
Transfer letter – rehabilitation
Notes
Model letter
Paragraph one: patient / condition / request
Details: Patient – Mr Mc Donald. Condition – total left knee joint replacement operation. Request – rehabilitation
Thankyou for accepting Mr Mc Donald, who has recently undergone a total left knee joint replacement operation performed by specialist Mr B Mossley, for rehabilitation.
Paragraph two
Details: osteoarthritis (past 10 years), gout (since 2010), smoker – 20 cigarettes/day, hypertension, obesity – BMI 35, hypocholesteremia, alcohol > 6-10 SD/day, penicillin allergy as a child
Mr Mc Donald has been suffering from osteoarthritis for the past 10 years and was diagnosed with gout since 2010. He is obese (BMI 35), has hypertension and hypocholesteremia, and he smokes and drinks alcohol excessively. Furthermore, as a child, he experienced a rash after taking penicillin.
Paragraph three
Details: Discharge medications are Zyloric, Karvina, Lipitor, paracetamol, ibuprofen, and a nicabate patch (please see the attached list of dosages)
Paragraph four
Details: significant post operation pain, morphine inadequate, ketamine infused, ongoing pain following, amitriptyline commenced – ceased due to urinating difficulty, slow to mobilize partly from pain, catheter specimen of urine (CSU) – Staph. Saphrolyticus, keflex given in addition to antibiotics, insomnia noted
Mr Mc Donald complained about significant post-operation pain, which couldn’t be relieved by both morphine and ketamine, so amitriptyline was administered, but was eventually stopped because Mr Mc Donald experienced urinating difficulties. Mr Mc Donald also displayed limited mobility due to pain. The catheter specimen of urine revealed that Mr Mc Donald was infected by Staph. Saphrolyticus for which he was treated with Keflex and antibiotics. In addition, Insomnia was noted.
Paragraph five
Details: Treatment plan – review of system, specialist at 6 week (appointment made 7/9/18), significant rehab including physiotherapy and occupational therapy home visit to assess suitability and fitness of returning to caravan, social work, drug and alcohol input appreciated, sleep studies? OSA
I would appreciate if you could conduct a thorough review of system on Mr Mc Donald. Please provide a rehabilitation, including: physiotherapy and occupational therapy home visit, to ensure that Mr Mc Donald’s condition is fit enough prior to allowing him to return to his caravan. Both social work, drug and alcohol counselling, and sleep studies should be also incorporated if possible.
Please note that Mr Mc Donald has an appointment with Mr Mosley 6 weeks post-operatively on 7/9/18
Should you have any questions, please do not hesitate to contact me.