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.

1
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

2
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.

3
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]

4
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

5
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.

6
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]

7
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

8
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

9
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.

10
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]

11
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.

12
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.

13
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

14
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.

15
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.

16
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)

17
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.

18
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.

19
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.

20
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]

21
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.

22
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

23
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.

24
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]

25
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 + +

26
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.

27
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

28
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

29
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

30
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.

31
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

32
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

33
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.

34
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

35
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

36
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

37
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.

38
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

39
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]

40
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

41
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.

42
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]

43
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

44
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

45
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.

46
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]

47
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

48
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.

49
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]

50
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

51
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

52
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.

53
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]

54
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

55
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

56
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

57
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.

58
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]

59
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.

60
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.

61
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]

62
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

63
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)

64
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.

65
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

66
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

67
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.

68
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

69
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

70
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.

71
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]

72
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 ↑

73
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

74
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.

75
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]

76
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

77
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

78
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.

79
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]

80
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

81
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

82
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.

83
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]

84