Grade B OET Letter Sample | Mrs Kathy Jonas Shawn
OET Case note
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Grade B OET letter sample
Dr Anita Arora
Melbourne Maternity Centre
East Melbourne 3007
19 January 2021
RE: Mrs Kathy Jonas Shawn, 26 years
Dear Dr Arora
I am writing to refer Mrs Kathy Jonas Shawn, G2P0, who is in the 20th week of gestation and shows signs/symptoms of pre-eclampsia. Your expert assessment and monitoring would be highly appreciated.
Today Mrs Shawn came with complaints of dizziness, headache, nausea, vomiting, blurred vision, abdominal pain, and vaginal spotting which started a day ago. Her pregnancy was confirmed at 5 weeks of gestation. She was started on aspirin 100 mg and counselled to make weekly antenatal visits which she did not adhere to.
On examination, Mrs Shawn was found to be confused but oriented to person, place and, time. Her blood pressure was 152/90, pulse 90 and respiratory rate 22.
Notably, she had bilateral pitting pedal edema, facial puffiness, periorbital edema and, mild right upper quadrant abdominal tenderness felt on deep palpation. Fundal height was 23 cm with oblique fetal lie and faintly audible fetal heart sounds.
Mrs. Shawn had miscarried /lost her first pregnancy at 12 weeks of gestation due to pre-eclampsia 18 months ago. Back then she had the same symptoms as she has now and, she was prescribed aspirin. Three months later, she was diagnosed with antiphospholipid syndrome. No treatment was provided due to asymptomatic status but she was counselled about future pregnancies. In addition, she had pelvic inflammatory disease 8 years ago, which was treated with a two-week antibiotic course.
Mrs Shawn is allergic to pollen and dust mites and she has been using Albuterol inhaler for Asthma for the last 7 years. She smokes 10 cigarettes daily with occasional crack and alcohol intake. Mrs. Shawn’s mother is diabetic and hypertensive.
In view of the above, Mrs Shawn requires expert monitoring and blood pressure control to prevent progression to eclampsia.
If you have any queries, please contact me.
Yours sincerely
Doctor
