Mrs. Larissa Zaneeta OET Letter
Read the case notes below and complete the task that follows
Writing Sub-Test
Doctors
Time allowed: 5 minutes reading time (no writing) 40 minutes writing time
Mrs. Larissa Zaneeta is a patient in your general practice. Read the case notes below and complete the writing task that follows.
Case notes
Mrs. Larissa Zaneeta
38 year old marketing manager, married, one child (4 year old boy)
Past history unremarkable, no medications
11/07/05
Complains of tiredness, difficulty sleeping for 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, prescribed sleeping tablets
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 over failure to conceive
Plan: discussed nature of conception – takes time, patience
discussed frequency sexual intercourse
discussed methods – temperature / cycle
18/01/07
Expressed anxiety over 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 gynecologist at 123 Church St. Richmond 3121. The main part of the letter should be approximately 180-200 words long.
Do not use note form in the letter. Expand the case notes where relevant into full sentences.
Grade B OET Letter Sample
Dr. Elveira Sterinberg
Gynecologist
123 Church St
Richmond, 3121
February 2nd, 2007
Dear Dr. Sterinberg,
Re: Mrs. Larissa Zaneeta, 38 years of age
I am writing to refer a 38-year-old woman who has difficulty conceiving despite trying and normal health condition of the couple. Your assessment and management of her condition by determining the cause and addressing her problems would be highly appreciated.
On January 25th, 2007, Mrs. Zaneeta and her supportive husband came here to discuss the possibility of the male factor in the couple’s reproductive problems. He reportedly had no issues in his sexual activities and his physical examination was unremarkable. Subsequently, his semen analysis revealed a normal finding.
Mrs. Zaneeta first presented here on July 11th, 2005 complaining of tiredness and insomnia caused by work-related stress. Although she was busy at work, she was planning to have another baby in the following year. Upon examination, it was found that she was slightly hypertensive, restless, tired and pale.
She was diagnosed with stress-related anxiety. Therefore, she was advised to practice relaxation technics and reduce her working hours. Sleeping pills were also prescribed.
A year later, Mrs. Zaneeta became worried about trouble conceiving after stopping OCP for 4 months. She still had monthly periods and experienced insomnia and stress from work which had never lessened. She was told about the nature of conception and various helpful measures to get pregnant.
On January 18th, 2007, about six months from the previous visit, Mrs. Zaneeta was crying during a consultation about her inability to conceive. She seemed to have lost hope and felt that she was too old to conceive. Her general physical examination was normal. Pelvic examination and a Pap smear were done. The assessment of her condition was similar to the previous one. Therefore, Valium was prescribed and her husband was advised to accompany her during the next visit.
Mrs. Zaneeta, married with a one 4-year-old son, is a marketing manager. She has insignificant past history and takes no medications.
If you require more information please do not hesitate to contact me.
Yours sincerely,
Doctor
