Mrs. Carol Potter OET Letter

Notes

You are a doctor at Stillwater Private Practice. You are examining a 70 year old woman who believes she has worsening arthritis.

Patient details

Name: Mrs. Carol Potter

DOB: 30.12.1947

Address: 21 Gumtree Road, Stillwater

Medical history:

2008: Osteoarthritis (OA) – mostly of hands and knees

2015: Hypertension (HT) – well controlled

2016: Skin cancer removed

2016: Insomnia – 2 years, intermittent, Urinary tract infections (UTIs) – intermittent

Medications

Ramipril 5mg daily

Panadol Osteo (extended release paracetamol 2 tablets

Temazepam 10 mg nocte p.r.n

Family history:

Mother – breast cancer

Social background: Administrative assistant (retired)

Presenting complaint: pain in L knee with walking for last 12 months. Now quite severe – not relieved by regular Panadol Osteo. Pain can even occur at rest after a long walk.

Treatment record

23.02.18

Subjective: No joint swelling / redness

No recent injury to knee

R knee – some pain on walking, not nearly as bad as L knee

On examination:

Evidence of ROM of L knee due to pain

No swelling

Tender to pressure along joint

Treatment:

Referral for X ray of L knee, blood tests

Review appointment to discuss results tomorrow

Prescribe pain relief – naproxen 250 mg b d

24.02.18

Test results

X-ray: Evidence of severe OA in L knee – osteophytes and loss of joint space

Patella appears normal

No evidence of fractures

Blood: FBE, UEC (normal)

Assessment: Likely worsening OA

Treatment: Arrange physiotherapy

Analgesia

Referral for surgical consultation – ? knee joint replacement

Using the information given in the case notes, write a letter of referral to Dr Waters, a surgeon at Stillwater Private Hospital, for a surgical consultation. Address the letter to Dr Leigh Waters, Surgeon, Stillwater Private Hospital, 54 Main Street, Stillwater.

In your letter

Expand the relevant notes into complete sentences.

Do not use note form

Use letter format

The body of the letter should be approximately 180-200 words

Sample letter

Dr. Leigh Waters

Surgeon

Stillwater Private Hospital

54 Main Street,

Stillwater

February 24th, 2016

Dear Dr. Waters,

Re: Mrs. Carol Potter, D.O.B. December 30th, 1947

I am writing to refer a 69-year-old woman who is suffering from worsening arthritis of her left knee. Your assessment and management of her condition through a discussion on benefits of knee joint replacement would be highly appreciated.

Yesterday, Mrs. Potter came into my practice with a year long history of worsening pain in the left knee associated with walking despite taking Panadol Osteo. Pain was present in the other knee as well but with a lesser degree of severity.

Neither recent history of trauma nor symptoms of infective arthritis existed. Upon examination, palpable tenderness along the joint line and a limitation of the left knee movement were noticeable. There was no joint effusion. She was prescribed naproxen 250mg twice daily, and an x-ray of the left knee along with relevant blood tests were requested.

Today, Mrs. Potter returned to discuss the results of her investigation. While FBC and UEC results were normal, the X-ray showed a strong evidence of severe osteoarthritis. Her initial diagnosis was worsening osteoarthritis of the left knee.  She was prescribed an increased dosage of analgesia and was referred to a physiotherapist. A surgical consultation was also recommended.

Mrs. Potter is a retired administrative assistant. She has been in well controlled hypertensive state for over a year. Osteoarthritis of hands and knees has affected her daily activities since 2006. Her current medications are ramipril 5mg daily, Panadol Osteo 2 tablets three times daily and temazepam 10mg for insomnia. Her family history is unremarkable.

If you need more information please do not hesitate to contact me.

Yours sincerely,

Doctor

Manjusha Nambiar

Hi, I'm Manjusha. This is my blog where I give IELTS preparation tips.