TIME ALLOWED: READING TIME: 5 MINUTES September 2015
WRITING TIME: 40 MINUTES
Read the case notes below and complete the writing task which follows.
notes:
Mrs Lucy Clarke is a patient in your General Practice.
Patient details
Name: Mrs Lucy Clarke
DOB: 11 March 1951
Residence: 23 Mountain Drive Coast City
Social background: 64-year-old retired office clerk
Independent, lives at home with husband
Non-smoker, social drinker
20.09.15
Presenting complaint:
1 week history central crushing chest pain on exertion (3x, <15 mins duration)
Associated dyspnoea, radiation of pain down L arm
Relieved by rest
No palpitations, no orthopnoea (difficulty breathing on lying down), no paroxysmal
nocturnal dyspnoea (difficulty breathing at night)
Pt anxious - believes had a "heart attack"
Past medical history:
2001 - diabetes mellitus (OM) Type II (currently stable)
2003 - hyperlipidaemia
2005 - hypertension (HT)
Medications:
Sitagliptin (Januvia) 100mg per oral (p.o.) mane
Insulin (NovoMix30) 25 units subcutaneously (s.c.) b.d.
Atorvastatin (Lipitor) 40mg p.o. mane
lrbesartan (Avapro) 75mg p.o. mane
Family history: Mother - acute myocardial infarction (Ml) at 57 y.o.; died of ischaemic stroke at 59 y.o.
Examination:
T - 36.7°C, P - 80 regular, Ht- 164cm, Wt - 65kg
No peripheral oedema
Systems review - normal
Resting ECG - normal
Provisional diagnosis: Unstable angina
Plan:
Hospital admission for urgent assessment
Referral to Emergency Department cardiologist for update & further management
Counsel patient - advised on serious risk of Ml
Writing Task:
Using the information in the case notes, write a letter of referral to the Emergency Department
cardiologist, Dr Smith. Address the letter to: Dr David Smith, Cardiologist, Emergency Department,
Main Hospital, Coast City.
In your answer:
• Expand the relevant notes into complete sentences
• Do om use note form
• Use letter format
The body of the letter should be approximately 180-200 words.
