Occupational English test – Writing (Medicine)
Read the case notes below and complete the writing task which follows.
Notes:
Today’s Date: 07 March 2024
- Patient Name: Mrs. Jane Macintyre
- DOB: 01 March 1985
- Gravida 5, Para 2, Miscarriage ×2
- Current Pregnancy: Approximately 8 weeks (based on LMP: 12 Jan 2024)
- Children: 2 (aged 5 and 3)
Medical and Obstetric History:
First pregnancy:
- Severe pre-eclampsia at 32 weeks.
- Emergency Caesarean Section.
- Postpartum ICU admission (3 days); received magnesium sulphate.
- Neonate (Sam) weighed 2.1 kg; NICU stay: 2 weeks; required CPAP, no mechanical ventilation.
Second pregnancy:
- Uncomplicated.
- Delivered at full term.
- Neonate (Katie) weighed 3.4 kg.
Other obstetric history:
- Two miscarriages.
Thrombophilia risk:
- Heterozygous for Factor V Leiden mutation.
- Strong family history of thrombosis.
- Prophylactic LMWH (low molecular weight heparin) used in previous pregnancies.
Gynaecological history:
- Negative Pap smear in 2021.
- Current Presentation (07 March 2024):
- Confirmed pregnancy via home test.
- Mild dysuria for 3 days.
- No suprapubic tenderness; abdomen soft, non-tender.
- Fundus not yet palpable.
Vitals:
- BP: 120/80 mmHg
- Weight: 60 kg
- Height: 165 cm
- Urine dipstick: 3+ protein; 2+ nitrites; 1+ blood → Suggestive of urinary tract infection
Provisional Diagnoses:
- Early intrauterine pregnancy (~8 weeks gestation)
- Recurrent pregnancy with prior history of pre-eclampsia and thrombophilia
- Suspected urinary tract infection
Current Medications:
- Tinzaparin 3,500 units subcutaneously once daily (prophylaxis for thrombosis)
- Folic acid 400 micrograms daily (to continue until end of first trimester)
- Cephalexin 250 mg PO QID × 5 days (empiric for UTI)
Investigations Ordered:
- Full antenatal blood panel including:
- CBC, Blood group & Rh, Rubella IgG, Syphilis, Hep B, Hep C, HIV
Blood sugar
- Thyroid function tests.
- Midstream urine sample sent for MCS.
- Nuchal translucency scan planned (at 11–13 weeks gestation)
Referrals and Plan:
- Referral to Consultant Obstetrician.
Other referrals:
- Genetic counselling for antenatal screening (Down Syndrome, trisomy 18/13)
- Information provided about Greenslopes Screening Centre for NT scan
Follow-up:
- Review pending urine culture result and modify antibiotic if required
- Forward antenatal test results to the obstetrician once available
- Monitor for early signs of pre-eclampsia (BP, proteinuria).
Writing Task:
Using the information in the case notes, write a referral letter to Dr Sara Choi, an obstetrician, requesting further antenatal evaluation and management of Mrs Jane Macintyre. Include relevant medical background, current presentation, investigations ordered, and provisional management initiated. Address the letter to Dr Sara Choi, Consultant Obstetrician, Sage 656 Pacific Highway, Chatswood NSW 2067 (Corner of Pacific Highway & Freeman Road).
In your answer
- Expand the relevant case notes into complete sentences.
- Do not use note form.
- Use correct letter format
The body of the letter should be approximately 180–200 words.
