Uses of for, since and over

For Since Over

For is used to describe a Since is used to refer to the Over uses similar time markers
period of time start of period of time to for but is used to express a
change in condition, or to
• I have been treating • I have been treating describe a repeated event.
the patient for 3 years. the patient since 2007. • The patient's condition
has deteriorated over
• The patient has been • The patient has been the past 3 months.
on this medication for on this medication (change in condition)
6 months. since January.
• The patient has
• I haven’t seen the • I haven’t seen this presented several times
patient for 1 year. patient since December over the last
2009. year. (repeated event)
• The patient has been in
pain for 5 hours. • The patient has been in • The patient's back pain
pain since 10am. has worsened over the
• The patient has been last week.(change in
waiting for 15 minutes. • The patient has been condition)
waiting since 11.45am.
• He has been • He has tried to quit
complaining of back • He has been smoking several times
pain for a week. complaining of back over the past 25 years.
pain since last week. (repeated event)
• He has not had bowel
motions for 3 days. • He has not had bowel • The patient has
motions since experienced seizures
• He has been a smoker Saturday. on 3 occasions over
for a period of 25
the past year.(repeated
years. • He has been a smoker
event)
since 1985.

Handy Tip
When using time markers such as ...for the past 20 years, ...for the last 3months, ...for the next 3
months or .... for the previous 3 months always use the definite article "the" as it its function is
to specify a particular period of time.
 Present Perfect

Present perfect tense is used to describe an event which starts in the past and continues until the
present.
Mastery of this pattern is an essential for writing successful referral letters. Three common ways to
form present perfect when writing referral letters are as follows:

Present Perfect Simple Present Perfect Progressive Present Perfect Passive

Form: have/has+ past Form: have/has+been Form: have/has +been+ past
participle +____ing (present participle) participle
• I have treated Mr. • I have been • Mr. Smith has been
Smith at this hospital treating Mr. Smith at treated at this hospital
for 3 years. this hospital for 3 for 3 years(..by Dr X).
years.
• Dr X has treated Mr. • They have been
Smith at this hospital • Dr X has been treated at this hospital
for 3 years. treating Mr. Smith at for 3 years(..by Dr X).
this hospital for 3
years.

Present perfect is often combined with for/since/over. Compare the usage below and note time
markers used.

Common Errors

Incorrect Correct
• The patient was diagnosed • The patient has had hypothyroidism since
hypothyroidism since 2007 2007. (present perfect)
Explanation: Past tense cannot be used with • The patient was diagnosed with
for or since hypothyroidism in 2007. (simple past)
• She has been problems with • She has been having problems with arthritis
arthritis in her hands. in her hands since 2007. (present perfect
Explanation: Problems in this sentence is a progressive)
noun so you can not use “been” with a • She has had problems with arthritis in her
noun. You must use have or has + noun or hands since 2007.(present perfect simple)
been+ ___ing verb. You can also use been
+ adjective • She has been arthritic since 2007. (present
perfect simple +adjective)
• She has had arthritis since 2007. (present
perfect simple +noun)
 • He is smoking 2 packs of cigarettes • He has been smoking two packs of
a day for the past 25 – 30 years. cigarettes a day for the past 25-30 years.
(present perfect progressive)
• Over the past week she remains free
from severe pain and has been able • Over the past week she has remained free
to tolerate a fluid diet. from severe pain and has been able to
tolerate a fluid diet.(present perfect simple)
• Also, there is an ulcer on the right
lower lateral border of the tongue • Also, there is an ulcer on the right lower
which is present for more than one lateral border of the tongue, which has
year. been present for more than one year.
(present perfect passive)
• Mr. Diamond is a patient of mine
since 2000 • Mr Diamond has been a patient of mine
since 2000.(present perfect simple)
• Mr. Eddy is a known smoker for
25-30 years. • Mr. Eddy has been a smoker for 25 years.
Explanation: The verbs in these sentences (present perfect simple)
are in simple present tense. Present perfect
needs to be used because you are referring
to a time period which started in the past
and has continued to the present.
• Mrs. Brown has been presenting to • Mrs. Brown has presented to me on several
me on several occasions over the occasions over the past few months.
past few months.
Explanation: Progressive form not
required.

Simple Past or Present Perfect

There is often confusion of whether to use simple past or present perfect tense. The basic rule to
remember is if you are referring a particular time in the past then you must use simple past tense. If
you are referring to a period of time that starts in the past and continues up to now use present
perfect tense.

There are some common time markers used with simple past and present perfect. It is important to
study, learn and use these tenses correctly when writing referral letters as you must refer to both past
events and periods of time leading to the present.

Common Errors

Incorrect Correct
• She has underwent triple coronary • She underwent triple coronary bypass
bypass surgery on 10.08.09 surgery on 10.08.09
 Time Markers with Simple Past Time markers with Present Perfect
• He sucked his thumb until he was 5. • He has been sucking his thumb for five
years.
• Mrs. Kelly had diverticulitis when she
was a teenager. • Mrs. Kelly has had diverticulitis for the
last 12 years.
• He first came to see me in 2004.
• He has been seeing me since 2004.
• The patient didn’t respond to treatment.
• The patient hasn’t responded to
• The patient was diagnosed with treatment yet.
cancer 3 months ago.
• The patient has shown no signs of
• The patient stopped taking improvement up to now.
medication yesterday.
• The patient has stopped taking
medication recently.

Active and Passive Verb Formation

In writing a referral letter it is necessary to use a variety of verb forms including both active and
passive verbs. Using active verbs is good when you wish to create a personal tone or impart
subjective information. However, passive verbs and sentence structures enable the writer to be more
objective and focus attention on what is most important in a sentence such as the patient, procedures
and treatment rather than on themselves.
Compare
1. I advised the patient to stop smoking.

2. The patient was advised to stop smoking (focus on the patient)

1. I advised her to do bed exercises to prevent further complications such as deep vein
thrombosis.

2. Bed exercises were advised to prevent further complications such as deep vein
thrombosis.(focus on the treatment)
1. You need to take Flucloxacillin capsules twice a day for a duration of 2 weeks.

2. Flucloxacillin capsules need to be taken twice a day for a duration of 2 weeks.(focus

on the medication)
To form the passive, use the be verb (be, is/ are; was/were; has been/have been) + past participle as
described in the table below.

Active Passive
Present simple Present simple
• The patient takes aspirin daily. • Aspirin is taken daily.
Present simple continuous Present simple continuous
• The patient is taking aspirin daily. • Aspirin is being taken daily.
 Past simple Past simple
• The patient took aspirin daily. • Aspirin was taken daily.
• The patient took 3 tablets daily. • 3 tablets were taken daily.

Past simple continuous Past simple continuous

• The patient was taking aspirin daily. • Aspirin was being taken daily.
Present perfect Present perfect
• The patient has taken aspirin daily for a • Aspirin has been taken daily for a
period of one year. period of one year.

• The patient has taken aspirin, noten and • Aspirin, noten and normison have been
normison for a period of one year. taken for a period of one year.

Present perfect continuous Present perfect continuous

• The patient has been taking aspirin • Nil: This form is rarely used in the
daily. passive.
Past perfect Past perfect
• The patient had taken aspirin daily for a • Aspirin had been taken daily for a
period of one year. period of one year.

• The patient had taken aspirin, noten and • Aspirin, noten and normison had been
normison for a period of one year. taken for a period of one year.

Past perfect continuous Past perfect continuous

• The patient had been taking aspirin • Nil: This form is rarely used in the
daily. passive.

Future Future
• The patient will take aspirin in the • Aspirin will be taken in the evening.
evening
Modal form Modal form
• The patient should have taken aspirin in • Aspirin should have been taken in the
the evening. evening.

Please review the list of common mistakes below.

Incorrect Correct
• She was performed a colostomy • A colostomy was performed with a partial
accompanied with a partial bowel resection.
bowel resection.
• A colostomy was performed on the patient by
the doctor with a partial bowel resection.
The first example is better as it more concise and also it
is obvious the roles of patient and doctor so it is
unnecessary to state them.
 • As per the doctor’s order, we • As per the doctor’s order, daily home
were organized daily home visits were organized. (passive)
visits.
• As per the doctor’s order, we organised daily
home visits. (active)
Both sentences are grammatically correct but the first
example is preferred because it focuses attention on the
procedure.
• On 9.7.06 he was presented to • On 9.7.06 he presented to me for his regular
me for his regular check up. check up. (active)
Active voice is preferred here as the patient is the
subject and most likely presented himself.
• On the subsequent visit the • On the subsequent visit the treatment
treatment options was discussed. options were discussed.
Because the noun is plural the plural verb “were” is
required.

• She had done colonoscopy 3 • A colonoscopy was done 3 years ago.

years ago.
• She had a colonoscopy done 3 years ago.
In these sentences it is unimportant who performed the
colonoscopy so passive voice is used.
• Initially, she came to me on • Initially, she came to me on 14/01/2006 for a
14/01/2006 for a general check general check up and her blood pressure was
up and was found her blood found to be 160/90.
pressure 160/90. After the conjunction and a subject is required.
• In addition, her baby will need • In addition, the baby’s growth and general
to monitor his growth and health conditionwill need to be monitored
general health condition Future form of the passive.
• Noten 50mg 1/2 tablet daily was • Noten 50mg 1/2 tablet daily was prescribed
prescribed while Zocor and while Zocor and Calcium Caltrate were
Calcium Caltrate were continued continued to be taken
taking.
• Today at my surgery attended • Today, Mr.
Mr. Attard complaining of pain Attard attended surgery complaining of pain in
in his upper left molar. his upper left molar.
Use active form here as you need to focus on your
patient, not your surgery

Past Perfect

Past Perfect is an important tense in referral letters. The main functions of this tense are:
• When used with simple past it allows the writer to distinguish the order of events:

o She had not been able to conceive over the previous four months and as a
result she was suffering from depression. This means: first she could not conceive,
 then she became depressed.

• When used in reported speech. The case notes may describe the patient's condition at
a time in the past, i.e patient found blood in toilet bowl 2 times. This can be written in the
referral letter as follows:

o At today’s consultation, Ms. Leon reported that there had been blood in the
toilet bowl on 2 occasions.
So the main benefit of using past perfect is that it allows the writer to express the order in which
certain health events occurred logically and clearly.

Handy Hint 1
Do not use past perfect when describing one past event as it is not necessary.
Compare
• The patient had been feeling unwell last week.(incorrect if 1 past event described)

• The patient was feeling unwell last week. (correct)

• The patient had been feeling unwell last week and was admitted to hospital for
observation. (correct as 2 past events need to be distinguished)
Handy Hint 2
Past perfect is often used with the word previous instead of ago to demonstrate that you are referring
to a time before a particular date in the past, not the date you are writing the letter. See below for
examples.

Incorrect Correct
• She presented to me on 03/07/2010 for a regular • She presented to me on
check up because she experienced several episode 03/07/2010 for a regular
of heart flutter over the past few weeks. check up because she had
experienced several
o Past perfect tense is necessary here (had episodes of heart flutter
experienced) to differentiate what happened over the previous few
prior to the check up, which is also in the weeks.
past.

o As your meaning is prior to 03/07/10 and

not the day of writing the letter, you should
use the word previous instead of past.
• On review two weeks later, the frequency of • On review two weeks later,
headache decreased. the frequency of
headache had decreased.
o Use past perfect to indicate that frequency
of headache had decreased prior to the
consultation.
• A review on 25/04/10 showed the patient’s general • A review on 25/04/10
health improved and her blood pressure dropped to showed the patient’s general
140/85 and she lost 4 kg. healthhad improved and her
blood pressure had
o Past perfect is used when describing a dropped to 140/85 and
condition that was true at a certain time in she had lost 4kg.
the past.
• She presented to me yesterday evening with • She presented to me
abdominal pain, mostly on the left iliac fossa, and yesterday evening with
was since 24 hours. abdominal pain, mostly on
the left iliac fossa,
o Note that in the correct version 3 different which had been
times need to be considered occurring for
the previous 24 hours.
2. The present i. e today: time of writing

3. Yesterday evenings consultation

4. Symptoms which occurred before yesterday's
consultation.
• She was admitted in Royal Brisbane and Women’s • She was admitted in Royal
Hospital on 24/07/08 because she collapsed at Brisbane and Women’s
home. Hospital on 24/07/08
because she had collapsed at
o Use past perfect tense to create a time line, home.
so past perfect indicates the collapse
occurred before the admission.
• Initially she presented to me in July 2010 with a • Initially she presented to me
complaint of chest discomfort for three weeks. in July 2010 with a
complaint of chest
o If you use this time expression: for a few discomfort which had been
weeks then you must either use a relative present for three weeks.
clause and past perfect verb tense, or the
very concise and useful expression: • Initially she presented to me
of______duration. in July 2006 with a
complaint of chest
discomfort of 3 week
duration.
• Mrs. Jones had taken Microgynon 30 for the • Mrs. Jones had
previous 5 years but had stopped in May 2009. taken Microgynon 30 for
the previous 5 years
o There is no need to use past perfect twice. but stopped in May 2009.
• On rechecking at 10.45pm, her condition has • On rechecking at 10.45pm,
further deteriorated and an ambulance was arranged her condition had further
for transfer to hospital. deteriorated and an
ambulance was arranged for
o Use past perfect and simple past together to transfer to hospital.
distinguish the order of events i.e her
condition deteriorated then an ambulance
was called.
 Subject-Verb Agreement

Subject verb agreement is an area where accuracy is important. Below are some important rules
which you should remember.

Singular subject & verb Plural subject & verb Explanation

• The suture has been • The sutures have been ITs either singular in one or
removed. removed. plural in all.

• One of the - All of the medications are

medications is unavailable.
unavailable.

• One of the • All of the

medications has side medications have side
effects. effects
• Mrs. Pratt lives in rental • Mr. & Mrs. Pratt live in
accommodation. rental accommodation.
• He needs to be assisted • They need to be assisted
with activities of daily with activities of daily
living. living.

Common Errors

Incorrect Correct
• Alison’s school medical record reveals • Alison’s school medical record reveals
that her attendance have been declining that her attendance has been declining
in recent past. in recent past.
• All these findings has been confirmed • All these findings have been confirmed
with bite-wing radiographs. with bite-wing radiographs.
• I am writing to refer this patient who I • I am writing to refer this patient who I
suspect is suffering from rheumatic suspect is suffering from rheumatic
fever and need urgent admission. fever and needs urgent admission.
• I believe that the teeth 65 and 54 needs • I believe that the teeth 65 and
to be extracted followed by space 54 need to be extracted followed by
maintainer. space maintainer.
• Threadworms looks like fine pieces of • Threadworms look like fine pieces of
cotton thread that can grow up to 1.5 cotton thread that can grow up to 1.5
cm long. cm long.

• A threadworm looks like fine pieces of

cotton thread that can grow up to 1.5
cm long.

Articles Usage with Countable & Uncountable Nouns

Whether an article is required or not depends on the noun that follows. For this purpose nouns can
be classified into two types: countable & uncountable nouns. The difference is based on whether the
noun can be counted or not. For example complaint is a countable noun as it can be counted.
Therefore it is possible to say 1 complaint or 2 complaints. Advice on the other hand cannot be
counted so it is not possible to say 1 advice or 2 advices , The correct expression is some/any advice
or the expression a piece of advice.

Countable nouns
These nouns have a singular form and plural form.

Singular
In the singular form an article is usually used before the noun. Example: The doctor received a
complaint from her patient.
NB. Exceptions: The article can be left out if it is replaced with another determiner such as his/her or
this /that or any/each/every. E.g. The doctor listened to each complaint. Her complaint was recorded.

Plural
In the plural form the article is usually not used before the noun. Example: The doctor received
complaints from her patients.

Remember: Always use articles when referring a particular job such as: doctor/dentist/nurse/
pharmacist/physiotherapist/teacher etc etc.

Countable Singular form Plural form

nouns Note the use of an article before Note the absence of the indefinite articles a/
each noun in singular form, either an before each noun in singular form, but
as a/an/the the definite article
abscess The patient had an abscess on her The patient had 3 abscesses on her gum.
gum.
ache The patient reported a dull ache The patient suffered from aches and pains.
in her abdomen.
accountant Mr. Hagen is an accountant. Mr. & Mrs. Hagen are both accountants.
appointment A follow-up appointment was The patient did not attend her follow-up
scheduled. appointments.
cavity The cavity was exposed. The cavities were exposed.
check up The patient attended for a check- Regular check-ups will keep you healthy.
up.
complaint If you have a complaint, tell your If you have any complaints, tell your
doctor. doctor.
condition You have a condition known as There are 3 conditions which can indicate
tuberculosis. the presence of cancer.
deposit A carious deposit was evident on Carious deposits were evident on teeth 32 &
tooth 32. 33.
doctor The patient has not seen a doctor Three doctors were involved in the
for several years. treatment of the patient.
episode The patient had an episode of The patient reported 3 episodes of heart
heart flutter. flutter.
examination An examination is necessary to Blood urine examinations revealed no
rule out cancer. abnormalities.
gum The gum surrounding tooth 23 The gums were infected.
was inflamed.
increase There was an increase in the size The patient presented with numerous
of the swelling. swellings.
interpreter An interpreter is required. Interpreters will be required.
 investigation An investigation is required to Investigations are required to rule out bowel
rule out bowel cancer. cancer.
limp The patient walked with a limp. All the patients had limps.
parasite The threadworm is a parasite. Threadworms are parasites.
lip The patient had a swollen lip. The patient had swollen lips. (both lips)
(one lip)
smoker She is a smoker. They are smokers.
operation An operation is necessary. Two operations are necessary.
painkiller The patient requested a painkiller. Painkillers are not necessary with this
procedure.
physiotherapis An appointment needs to be a Two physiotherapists work at this
t arranged with a physiotherapist. rehabilitation centre.
result The patient hoped for a positive The results were positive.
result.
review A review was scheduled after 2 The nurse received positive reviews from
weeks. her patients.
sensation The patient reported a tingling The patient experience tingling sensations in
sensation in his fingers. his fingers.
social worker A social worker has been Two social workers have been arranged to
arranged to offer ongoing care. offer ongoing care.
teacher Steve is a teacher. Steve and Chris are teachers.
test A blood test was ordered. Blood and urine tests were ordered.
visit Please organise a visit by a social Regular visits by a social worker is required.
worker.

Uncountable nouns
These nouns cannot take a plural form such as: cancer, anaesthesia and information. For these words
no article is required. However, the definite article the as well as quantifiers such as some and any
can be used before the noun.

Uncountable Indefinite articles cannot be used with uncountable nouns. However

nouns definite article “the” as well as quantifiers such as some and any can be
used.
accommodation The patient lives in rental accommodation.
advice Advice on diet is requested.
assistance The patient will require assistance upon discharge.
attention The patient requires urgent attention.
behaviour On examination, the patient's behaviour was abnormal.
cancer The patient has cancer.
caries Deep caries were present on several teeth.
concentration The patient has poor concentration.
damage The scan confirmed damage to the medial cartilage.
discomfort If you experience discomfort, please consult your doctor.
information Should you require further information, please do not hesitate to contact me.
pain The patient experienced pain on palpation.
progress The patient has made good progress.
tissue She has healthy, soft tissue.
treatment The condition did not respond to treatment.
research Further research is required.
surgery The patient chose not to have surgery.
Common mistakes

Incorrect Correct
Wound on her left knee has been stitched. A wound on her left hand has been stitched.
I am writing to refer Marvin, 7 year old boy I am writing to refer Marvin, a 7 year old boy
who was admitted to hospital on 21/11/10. who was admitted to hospital on 21/11/09.
Mr Brown has been patient of mine for 7 years. Mr Brown has been a patient of mine for 7
years.
Please note, the patient has had prosthetic heart Please note, the patient has had a prosthetic
valve for year. heart valve for a year.
Examination revealed abscess on her gum. Examination revealed an abscess on her gum.
Apart from bruises to her body, X-rays reveal Apart from bruises to her body, X-rays reveal
that she has fracture of the right ankle. that she has a fracture of the right ankle.
Mr Jones had a heart surgery in 2009. Mr Jones had heart surgery in 2009.
The patient has a cancer. The patient has cancer.
She had a healthy soft tissue. She had healthy soft tissue.
He had lacerated lip and swollen gum. He had a lacerated lip and swollen gums.
The patient has pollen allergy. The patient has a pollen allergy.
The patient has tender right elbow joint. The patient has a tender right elbow joint.
The patient presented for regular check-up on The patient presented for a regular check-up on
12/2/10. 12/2/10.• Mentioned Information

New Information Vs Previously Mentioned Information

Indefinite Article: A or An
When you mention something for the first time the indefinite article a/an is required. This signifies to
the reader that it hasn’t been mentioned before.

Definite Article: The

When you mention something for the second and subsequent times that we mention it the definite
article the is required because we are referring a something which has been mentioned before.

Example: Initially, she came to me on 03/07/06 for a blood test. The results of the blood test were
negative.

Correct application of this rule creates cohesion in your letter as you are able to connect ideas, as in
the example above, where the reader knows which blood test is being referred. Conversely, incorrect
use can confuse the reader.

Example: Initially, she came to me on 03/07/06 for the blood test. The results of a blood test were
negative.

In the example above the ideas are not connected and the reader will be confused.
 Incorrect Correct
• The patient has the family history of diabetes. • The patient has a family history
Explanation: If it is the first time to give this of diabetes.
information then the indefinite article is required for
countable nouns.
• In addition, the pain in the right knee joint has • In addition, pain in the right knee
appeared over the last 2 days. joint has appeared over the last 2
days.
• Thank you for seeing, Mr and Mrs Conway,
who have presented to me for fertility advice. • Thank you for seeing, Mr and
Explanation: If it is the first time to give this Mrs Conway, who have
information and the word is an uncountable noun, presented to me for fertility
such as pain or advice, then no article is required. advice.
Note, this error has a big effect on meaning:the in this
case implies that this subject has been
mentionedpreviously, which of course it hasn't.
For more details on countable & uncountable nouns
click here
• Thank you for seeing this patient, an eight Thank you for seeing this patient ,an
year old girl who presented today with the eight year old girl who presented
broken left arm following the accident at his today with a broken left arm
school play ground.It has been forty minutes following anaccident at his
since accident. school play ground.It has been
forty minutes since the accident.

Referring to Something Specific

The definite article is used when referring to something specific. It is very important to include this
article to signify the information is specific.

Note: These articles are usually omitted in the case notes. This is because the case notes are in short
note form and standard grammar rules do not apply. However for referral letters it is necessary to
apply and adhere to standard grammar rules.

Incorrect Correct
 • She was on Microgynon 30 for • She was on Microgynon 30
previous 5 years. for the previous 5 years
• He has been a smoker for last 12 years. • He has been a smoker for the last 12
years.
• Mr. Roberts has been a resident at our
nursing home for past 2 years. • Mr. Roberts has been a resident at our
nursing home forthe past 2 years.
• This medication needs to be taken twice
a day for next 3 days. • This medication needs to be taken twice
Explanation: All the expressions above are a day for thenext 3 days.
referring to a specific period of time so a
definite article is required.
• Mrs Sangean is currently on following • Mrs Sangean is currently
medication: karvea 150mg daily, on the following medication: karvea
oroxinen 0.1 daily. 150mg daily, oroxinen 0.1 daily
Explanation:In this case, the writer is referring
to specific medication. i.e that which follows.
• The patient reported pain in left ankle. • The patient reported pain in the left
Explanation: Here the writer is referring to a ankle.
specific side, i.e not the right side but the left
side.
• Patient complained of chest pain. • The patient complained of chest pain.
Explanation: Patient requires an article to
indicate which patient the writer is referring to.
• Examination revealed a slightly swollen • Examination revealed a slightly swollen
joint and a tender spot on medial aspect joint and a tender spot on the medial
of it. aspect of it.
Explanation: Here the writer is referring to a
specific region, i.e not the anterior aspect but
the medial aspect.
• Based on above information, I believe • Based on the above information, I
the patient needs urgent admission to believe the patient needs urgent
hospital. admission to hospital.
Explanation: Here the writer is referring to a
specific information, i.e not the information on
the medical chart but the information written
above.
• Thank you for seeing this patient who • Thank you for seeing this patient who
presented at my surgery regarding tooth presented at my surgery regarding tooth
54 which has been temporary filled by 54 which has been temporary filled
school dental service. by the school dental service.
Explanation: Here the writer is referring to a
specific dental service, i.e not the community
dental service but the school dental service.
 Special Usage of Articles

There are some situations where you should always use the definite article and there are some
situations where the indefinite article is required. Understanding these rules can greatly reduce the
number of "minor" errors in your writing so please study these rules carefully.

Handy Hint!
Articles are usually omitted in the case notes. This is because the case notes are in short note form
and standard grammar rules do not apply. However for referral letters it is necessary to apply and
adhere to standard grammar rules including article usage.

Body Parts

The definite article "the" should be used when referring to parts of the body.

Incorrect Incorrect
• Pain in left groin. • Pain in the left groin.

• Pain in stomach. • Pain in the stomach.

• I suspect it to be adenoma of parotid • I suspect it to be adenoma of the parotid
gland. gland.

• Mr. Smith had an operation on a left • Mr. Smith had an operation on the left
knee. knee.

Names of Diseases
Do not use an article for names of diseases or conditions.

Incorrect Correct
• The patient is suffering from the high • The patient is suffering from high
blood pressure. blood pressure.
• Recently, the patient has complained of • Recently, the patient has complained of
the headache. headache.
• The patient was diagnosed with the • The patient was diagnosed with arthritis.
arthritis.
• The patient has had influenza for three
• The patient has had the influenza for days.
three days.

Same
Always use the definite article with this word.

Incorrect Correct
 • She has a family history of same disease • She has a family history of the same
that had been controlled by disease that had been controlled by
Risperidone. Risperidone.
• The children were treated by same • The children were treated by the same
dentist. dentist.
• The medication is same as last time. • The medication is the same as last time.

Articles with Gerunds

A gerund is the …ing form of a verb which takes on the grammatical function of a noun. It can be
the subject or object in a sentence. Usually no article is required with gerunds.

Incorrect Correct
• On review today, Mr Walker has • On review today, Mr Walker has
reduced the smoking from 20 to 10 reduced smoking from 20 to 10
cigarettes per day. cigarettes per day.

• The patient was advised to stop the • The patient was advised to stop
drinking. drinking.

Articles and Nominalisation

Nominalisation is a process where verbs can be turned into a "noun phrase". For example:The patient
sucked his thumb until he was five becomes The patient had a habit of thumb sucking until the age
of five.

Often in medical English, it is necessary to use nominalisation such as: The excessive drinking of
alcohol will adversely affect your health. The reduction of weight has led to improved health. It is
common in these cases to use an article before the nominalised expression.

The other benefit of using the style of writing is that it creates a formal tone and allows you to
summarise details from the case notes.

Incorrect Correct
• The patient is complaining of • The patient is complaining of
discomfort during passing of urine. discomfort during the passing of urine.

uses

Relative Clauses

In the introduction of a referral letter it is common practice to introduce the patient and provide
some relevant details relating to their situation or condition. The relative clause allows writers to do
this in a clear and concise manner.

Definition: A relative clause is the part of the sentence which provides information about the
patient.They can be divided into two types, defining and non-defining. Defining clauses provide
details about the noun being referred to. Commas are not required.
Non-defining clauses provide extra information about the noun being referred to but do not define
it.Commas are required.

Defining Non-defining
• I am writing to refer this patient who is • I am writing to refer this patient,who is
due to be discharged today. due to be discharged today, for
ongoing physiotherapy treatment.
Explanation: The relative clause defines the
object of the main clause i.e Which patient? The Explanation: The relative clause provides extra
patient who is being discharged. information (patient is due to be discharged)
about the object of the main clause but does not
define it. It could be removed from the
sentence and the meaning would still be clear: I
am writing to refer this patient for ongoing
physiotherapy treatment.
• I am writing to refer Mrs. Patterson, a • Mrs. Patterson, who is a 36-year-old
36-year-old married woman who is married woman, is suffering from mild
suffering from mild depression. depression.

Explanation: The relative clause defines the Explanation: The relative clause provides extra
object of the main clause i.e Who? Mrs. information (Mrs. Patterson is a 36 year old
Patterson, a 36-year-old woman. woman) about the subject of the main clause
n.b. In this sentence, the first comma allows but does not define it. It could be removed
extra information to be added about Mrs. from the sentence and the meaning would still
Patterson. be clear: Mrs Patterson is suffering from mild
depression.

Handy Tip
No name=no comma
In example 1 below, no comma is required as the relative clause is defining the person being referred
to. In example 2, the relative clause does not define the person being referred to because it is already
known. Therefore, If you include the patient's name, commas are required.
1. The doctor who performed the operation is from Iraq.

2. Doctor Yousif, who is from Iraq, performed the operation.

Incorrect Correct
• Mr. Holmes who lives with his wife in a • Mr. Holmes, who lives with his wife in
government flat, is an aged care a government flat, is an aged care
pensioner. pensioner.
Explanation: Commas required as it is a non- • Mr. Holmes lives with his wife in a
defining relative clause. You can also express government flat and is an aged care
this information in a compound sentence. pensioner.
• Mr. O'Riley, who lives alone in his own • Mr. O'Riley, who lives alone in his own
home, and works as a fencing home, works as a fencing contractor
contractor and has only one brother. and has only one brother.
Explanation: After the second comma a verb is
required. i.e Mr O'Riley works..
 • Mrs. Peterson who recently moved to • Mrs. Peterson recently moved to our
our retirement village following her retirement village following her
husband's death. husband's death.
Explanation: No relative pronoun needed here • Mrs. Peterson, who recently moved to
as it is a simple sentence. our retirement village following her
husband's death, has a history of
hypertension.
• Mr. Brown presented at my clinic today • Mr. Brown presented at my clinic today
with a complaint of fractured front teeth with a complaint of fractured front
in a traumatic car accident. teeth which occurred in a traumatic car
Explanation: A relative clause is required to accident.
define how the teeth were fractured. • Mr. Brown presented at my clinic today
Alternatively it can be written as two separate with a complaint of fractured front
sentences. teeth. This occurred in a traumatic car
accident.
• I am writing regarding Mr. Jones, a 35 • I am writing regarding Mr. Jones, a 35
year-old-male, who was recently year-old-male who was recently
diagnosed with with tuberculosis. diagnosed with with tuberculosis.
Explanation: Second comma not required as it
is a defining relative clause, i.e it defines Mr.
Jones
• I am writing to refer Mrs. Margaret • I am writing to refer Mrs. Margaret
Green, a 66 year old widow with three Green, a 66 year old widow with three
children, with complaints of chest pain. children who is complaining of chest
Explanation: Relative clause required here as pain.
two prepositional phrases is confusing.
• I am writing to refer, Ms. Abbot, a 58 • I am writing to refer Ms. Abbot, a 58
year old widow admitted with pain, year old widow who was admitted with
dehydration and nausea. pain, dehydration and nausea.
Explanation: Incorrect comma placement and
relative clause required.
• Mr. Fisher was admitted to hospital with • Mr. Fisher was admitted to hospital with
the diagnosis of obstructive artery the diagnosis of obstructive artery
disease and end with quadruple artery disease which required quadruple artery
bi-pass grafts. bi-pass grafts.
Explanation: A relative clause is required to
define the treatment.
• I am writing to refer this 14-year-old • I am writing to refer this 14-year-old
boy to you who came to me boy who came to me complaining of a
complaining of a sprained ankle. sprained ankle.
Explanation: The relative pronoun must follow
the noun it is referring to.
 • I am writing to refer this patient, a 39 • I am writing to refer this patient, a 39
year old widowed woman, who is under year old widowed woman who is under
our care after being injured in a car our care after being injured in a car
accident. accident.
Explanation: No comma required as it is a
defining relative clause.
• Mr. Roberts who is a 72-year-old • Mr. Roberts, who is a 72-year-old
retired gentleman was admitted to retired gentleman, was admitted to
hospital for acute cerebral infarction on hospital for acute cerebral infarction on
08/03/10. 08/03/10.
Explanation: Commas required as it is a non-
defining relative clause and provides extra
information about Mr. Roberts.
• I am writing to explain Mr. Clarke's • I am writing to explain Mr. Clarke's
current situation, who has been a patient current situation. He has been a patient
of mine for a long time. of mine for a long time.
Explanation: The relative pronoun must be • I am writing to refer Mr. Clarke, who
added directly after the person you are has been a patient of mine for a long
referring to. time. Currently, he is suffering
from........

Clauses of Contrast

Contrast can be expressed by joining two clauses with the following linking words: although/but/
despite/despite the fact that/even though/however/in spite of/on the other hand/whereas/while. A
comma is used to separate the two clauses as illustrated below.
•€Although her condition has improved, she is still very weak.
•€Her condition has improved, but she is still very weak.
•€Despite an improvement in her condition, she is still very weak.
•€Despite the fact that there has been an improvement in her condition, she is still very weak.
•€Even though her condition has improved, she is still very weak.
•€Her condition has improved. However, she is still very weak.
•€Inspite of an improvement in her condition, she is still very weak
•€While her condition has improved, she is still very weak.
Rules for linking words
•€Although/Even Though + clause (underlined below)
e.g. Although + her condition has improved, she is still very weak.
•€Despite/Inspite of + noun or gerund (underlined below)
e.g. Despite an improvement in her condition, she is still very weak.
Despite overcoming her illness, she is still very weak
•€Despite the fact that/Inspite of the fact that + clause (underlined below)
e.g. Despite the fact that there has been an improvement in her condition, she is still very
weak.
Despite the fact that her condition has improved, she is still very weak.
•€However : A comma is required after however
e.g. Her condition has improved. However, she is still very weak
 Common Mistakes

Incorrect Correct
•€Inspite of providing with exercises and •€Inspite of our provision of exercises and
compensatory techniques she was unable compensatory techniques, she was
to cope with training due to an increase unable to cope with training due to an
in pain. increase in pain.
Explanation: providing is incorrect, as it was the •€Inspite of being provided with exercises
patient who was provided excercise, in such and compensatory techniques, she was
cases you have 2 choices unable to cope with training due to an
1. Use a noun phrase In spite of our increase in pain.
provision of exercises
2. Use passive voice In spite of being
provided with excercise
•€Although she has improved, but she is still •€Although she has improved, she is still
very weak very weak.
Explanation: This sentence has two linking •€She has improved, but she is still very
words so one must be omitted. weak.

•€Despite of regular follow up, plaque and •€Despite regular follow up, plaque and
tartar were detected over cervical and tartar were detected over cervical and
bucal surfaces of the denture teeth. bucal surfaces of the denture teeth.
Explanation: There is no linking expression •€Inspite of regular follow up, plaque and
“despite of” tartar were detected over cervical and
bucal surfaces of the denture teeth.
•€Despite of this advice, he regularly drinks •€Despite this advice, he regularly drinks
2~4 glasses of wine every night as well 2~4 glasses of wine every night as well
as 1~2 glasses of scotch at weekends. as 1~2 glasses of scotch at weekends.
Explanation: As above •€Inspite of this advice, he regularly drinks
2~4 glasses of wine every night as well
as 1~2 glasses of scotch at weekends.

Clauses of Purpose

Purpose clauses allow the writer to express why a certain action was taken in the past or why a certain
action needs to be taken in the future. It can be expressed by joining two clauses with the following
linking words: in order to; so that. A comma is required when the subordinate clause comes before
the independent clause.
• In order to reduce weight, a low fat diet has been recommended.(quite formal and
suitable for referral letters)

• A low fat diet has been recommended in order to lose weight.

• A low fat diet has been recommended so that the patient can lose weight. (casual
expression and used more in informal writing or spoken English)
Rules
• in order to + infinitive: Further investigation is required in order to rule out bowel
cancer.
 • so that + past reference: A general anaesthetic was given so that the patient would not
feel pain.
• so that+ future reference: A general anaesthetic needs to be given so that the
patient will not feel any pain.
Handy Tip: in order to rule out + disease name is a useful phrase for introductions or conclusions.
• In order to rule out ectopic pregnancy, I would appreciate your urgent assessment.
• The patient wants to have a scan for nuchal translucency in order to rule out Down's
Syndrome.
Incorrect Correct
• In order for alleviation of pain, the • In order to alleviate of pain, the patient
patient was prescribed paracetamol. was prescribed paracetamol.
Explanation: In order must be followed by to +
infinitive verb, not for + noun

Clauses of Reason

In referral letters it is often necessary to state why a certain action was taken and clauses of reason
allow the writer to do this in a clear manner. It can be expressed by joining two clauses with the
following linking words: due to/due to the fact that; for this reason; because/ because of.
Examples

• Due to failure to progress and fetal stress, an emergency caesarean section was
performed.
• Due to the fact that there was failure to progress and fetal stress, an emergency
caesarean section was performed. (formal)
• There was evidence of poor progress and fetal stress. For this reason, an emergency
caesarean section was performed.
• Because there was evidence of poor progress and fetal stress, an emergency caesarean
section was performed.
• Because of failure to progress and fetal stress, an emergency caesarean section was
performed.
Rules
• due to/because of + noun (underlined below)
Example: Due to a low fat diet, the patient's health improved.
The patient's health improved due to a low fat diet.
Because of a low fat diet, the patient's health improved.
The patient's health improved because of a low fat diet.
• due to + gerund (-----ing form)
Example: Due to losing weight, the patient's health improved.
• for this reason+ clause (underlined below)
Example: The patient was placed on a low fat diet. For this reason,her health improved.
• because + clause
Example: Mrs Healy's health improved because she was on a low fat diet.
Because she was on a low fat diet, Mrs Healy's health improved .
• due to the fact that + clause
Example: The patient's health improved due to the fact that she was on a low fat diet.
Due to the fact that Mrs Healy was on a low fat diet, her health improved.
 Handy Tip: due to + ing form allows the writer to express meaning clearly and concisely so it is
useful in referral letters.

Comma placement
A comma is required when the subordinate clause comes before the independent clause. However, if
the independent clause comes first, no comma is required. Click here for more details.

Incorrect Correct
• The patient is feeling lonely and • The patient is feeling lonely and
isolated due to lose her usual social isolated due to losing her social
contacts. contacts. (clear and concise)

• The patient is feeling lonely and

Explanation: Incorrect word form and sentence isolated due to the fact that she lost her
structure after due to social contacts. (formal and a bit
wordy)
• His mother had difficulty in caring for • His mother had difficulty in caring for
both her son's illness and looking after both her son's illness and looking after
two other small children due to sick. two other small children due to her
Explanation: Incorrect word form and sentence sickness.
structure after due to • His mother had difficulty in caring for
both her son's illness and looking after
two other small children due
to being sick.
• Recently, the Mr Hutton stopped • Recently, the Mr Hutton stopped
playing sport because muscle soreness. playing sport because ofmuscle
Explanation: Incorrect word form and sentence soreness.
structure after because of • Recently, the Mr Hutton stopped
playing sport because he had muscle
soreness

Clauses of Time
A very important part of referral letters is summarising the patient history and order of events in the
case notes. The use of time conjunctions help the writer express these relationships clearly.
Commonly used conjunctions include: ago, during, when, while, since,first, on the next visit, at that
time,after, later, in .......... time etc. etc.

Example sentences
• The patient first saw me three months ago complaining of painful wisdom teeth.

• During hospitalisation, the patient had surgery to remove a suspicious lesion on his
lip.
• When Mr. Matthews is discharged, he will need assistance with showering and general
household chores.

• While you are on this medication, please do not drive or consume alcohol.
 • Since being admitted 3 weeks ago, the patient has steadily improved and is due to be
discharged today.
• The patient first attended me yesterday evening
• On the next visit, Peter's condition had worsened and he was very anxious.

• Mr. Hauritz initially presented at my clinic on 20/11/09. At that time, examination

revealed carious lesions on several teeth along with poor dental hygiene.
• On review after three months, she had made good progress with her weight
reduction.

• The patient was advised to reduce alcohol consumption, avoid heavy lifting and
review in three months time.

• A review consultation was scheduled for one month later.

Example paragraph

Six months ago, Mr. Roberts twisted his right ankle while playing golf. During the following
months, the patient experience intermittent attacks of pain which hindered his ability to work
effectively. On review after three months, the right ankle joint was x-rayed and the result appeared to
be satisfactory. However, when the swelling, pain and impaired improvement persisted, an MRI was
ordered which revealed a detached cartilage.Currently, Mr. Roberts does not have full mobility, and
is no longer capable of full-time employment on which, financially, his family depends.

Rules
• During + noun (underlined below)
Example: During his stay in hospital, Mr Mason's condition has improved.
• When + time clause (underlined below)
Example: When Ms. Song returned today, she was pale and distressed.
• While + clause (underlined below)
Example: While waiting in reception, the patient fainted.
• Ago + past tense (underlined below)
The patient had a liver transplant 12 months ago.

Comma Placement
A comma is required when the time clause comes before the independent clause.

Handy Tip
Correct verb tense is an important point to consider when writing time clauses. The important points
to remember are as follows:
• When the verb of the time clause is in present form, the verb in the main clause must
also be present or future form.
Example: While you display symptoms of fever and rash, you are still infectious.
• When the verb of the time clause is in past form, the verb in the main clause must
also be in past form.
Example: When the patient received his results, he fainted.
• When the verb in the main clause is in present perfect form,the verb of the time
 clause must be in present perfect form.
Example: While the patient has been in hospital, his condition has steadily improved.

Incorrect Correct
• Today, the couple presented at my • When the couple presented at my clinic
clinic. Mrs. Conway informed me that today, Mrs. Conway informed me that
her home ovulation prediction test her home ovulation prediction test
showed positive. showed positive.
Explanation: To demonstrate a higher level of • Today, when the couple presented at
English proficiency this information should be my clinic, Mrs. Conway informed me
expressed in a complex sentence rather than that her home ovulation prediction test
two simple sentences. showed positive.
• The patient has had placement of a • The patient had placement of a
prosthetic heart valve 12 months ago. prosthetic heart valve 12 months ago.
Explanation: has had is present perfect, but
simple past is required with the time
marker ago.
• I first saw Mrs. Smythe at my clinic last • When I first saw Mrs. Smythe at my
week , she urgently needed a new clinic last week , she urgently needed a
partial denture. new partial denture. (best choice)
Explanation: An adverb of time such as when • I first saw Mrs. Smythe at my clinic last
required to connect these two independent week and she urgently needed a new
clauses partial denture.

Compound Sentences and Coordinating Conjunctions

When writing referral letters it is necessary to take information from the case notes and write it in
complete sentences. The most basic way to do this is as a simple sentence. Simple sentences
commonly contain a subject, verb and object and are known as independent clauses.
Example: The patient is allergic to penicillin.

This method is suitable for information which is not connected to other information in the case notes.
However, it is more common to group information which is related into compound sentences. In the
sentence below ,two ideas are joined by the conjunctionand. Note that the subject for each clause is
different and each clause can function as a complete sentence

Example: I prescribed Panadol for his hand pain and he was advised to reduce weight and do
exercise.

Compound sentences are joined by conjunctions and they show the relationship between the ideas.
The most common conjunctions are:
and = the second clause contains a similar idea as the first

Example: She does not smoke and (she)drinks alcohol rarely.

but = the second clause contains an contrasting idea

Example: She does not smoke but (she) is a heavy alcohol drinker.
so=the second clause expresses a result or outcome

Example: She does not smoke or drink alcohol so her health is good.

One important decision for the writer to make is whether to include a subject in the second clause.
Basically, the rule is you need to add a subject after a conjunction if the subject of the second clause
is different to that of the first clause. Or if the sentence is very long.
•€I prescribed Panadol for his hand pain and he was advised to reduce weight and do
exercise. (In this case you must add a subject after and as the subject is different in the
second clause)
•€I prescribed Panadol for his hand pain and advised for weight reduction and exercise. (in
this case you can omit the subject Ias it is the same as the subject for the first part of the
sentence)
•€I prescribed Panadol for his hand pain and I advised for weight reduction and
exercise. (this is grammatically correct, but in terms of style not very good as it is clear
the subject remains the same, so need to repeat it)

Common Mistakes

Incorrect Correct
•€Nicole is a non-smoker and no drink alcohol or •€Nicole is a non-smoker and (she)
other drugs. doesn’t drink alcohol or take
Explanation: The sentence is not balanced and there is drugs.
no verb after the conjunction and
•€The parents say that immunizations were given at •€The parents say that immunizations
birth to both their children, but no record to were given at birth to both their
prove that. children, but they have no records
Explanation: No subject or verb after the to prove that.
conjunctionbut •€The parents say that immunizations
•€The wound has healed and free of infection were given at birth to both their
Explanation: Omission of subject and verb children, but there are no records
to prove that.
•€The wound has healed and
(it) is free of infection
•€Mr. Smith’s activities were restricted since last •€Mr. Smith’s activities were restricted
year by grinding pain in the left hip and had since last year by grinding pain in
difficulty in climbing and descending stairs. the left hip and he had difficulty
Explanation: No subject after the conjunction and, and in climbing and descending stairs.
note the subject for each clause is different. In the first •€Her blood pressure was 175/95
clause the subject is Mr Smith’s activities and in the and she took normison 1 tablet
second clause the subject is Mr Smith (not his activities) and 2 panadol at 10 pm
•€Her blood pressure was 175/95 and took
normison 1 tablet and 2 panadol at 10 pm.
Explanation: You must add a new subject here as it is
different to the subject of the first clause Her BP Vs She
 •€She is a widow and a resident at Golden Pond •€She is a widow and a resident at
Retirement Village, has a son in Warwick. Golden Pond Retirement
Explanation: This error is called a comma splice. A Village and (she) has a son in
comma splice is incorrect because two sentences cannot Warwick.
be joined with a comma alone. In this case you can join
the sentences with and.

•€Mr. Jones has been a patient of mine since 1999 •€Mr. Jones has been a patient of
and attending my clinic on a regular basis for mine since 1999 and (he) has
scaling and cleaning. been attending my clinic on a
Explanation: incomplete verb formation after and regular basis for scaling and
cleaning.

Parallel Structures & Balanced Sentences

The information in the case notes is usually written in note form, and therefore does not follow
conventional grammatical rules. However, when this information is organised into complete
sentences in the referral letter it is necessary to follow standard conventions of grammar and sentence
structure. This worksheet explains how to group information using parallel structures to ensure that
the sentences you write are grammatically balanced. This can be achieved by making sure that verbs,
adjectives, nouns, prepositions, phrases and clauses are parallel. Parallel structures within a sentence
are joined with coordinating conjunctions such as and/or as well as with commas. Here are some
examples:
With active verbs
•€He is now worried about his condition because he is overweight, lacks exercise
and smokes regularly
With passive verbs
•€During hospitalization, IV fluids were commenced and a transdermal patch was used for
her pain.
With nouns & noun phrases
•€He is now worried about his condition because of his increased weight, lack of
exercise and his habit of smoking.
•€He will require information about how and when to take his medication, how to stop
smoking and the necessity of doing regular exercise.
With gerunds
•€In order to handle the above mentioned effects be cautious when driving a
car, operating machinery or performing any hazardous activities especially
after taking your regular dose.
With prepositions
•€Threadworms resemble pieces of 1.5 cm cotton thread which is normally detectable at the
surface of the feces or around the anus at night.
With verbs in the conclusion
•€I am worried about Miss Jones and would appreciate your urgent assessment and treatment
as you think appropriate.
The important point to remember is that the structures must be balanced.
 Common Mistakes

Incorrect Correct
•€Sally initially presented alone to my clinic •€Sally initially presented alone to my clinic
on 27/12/07 with a 3-month-history of on 27/12/07 with a 3-month-history of
co n stip atio n an d asso ciated u sin g constipationand associated use of
laxatives laxatives
Explanation: The sentence is not balanced as
noun phrases
•€He has a family history of stroke and •€He has a family history
diabetic. of stroke and diabetes
Explanation: This sentence is not balanced as
stroke is a noun and diabetic is a adjective
•€Good hygiene should be maintained by •€Good hygiene should be maintained
taking a morning shower, using by taking a morning
individual towels, washing clothes daily shower, using individual
and to vacuum regularly. towels, washingclothes daily
Explanation: the final verb is out of balance and vacuumming regularly.
•€I am writing to refer this patient, a 26 year •€I am writing to refer this patient, a 26 year
old computer programmer, who is old computer programmer, who is
displaying sign and symptoms consistent displaying signs andsymptoms consistent
with subdural haematoma. with subdural haematoma.
Explanation: Both nouns should be in plural
form
•€His height is 170cm and weighing 99kg. •€His height is 170cm and weight is 99kg.
Explanation: unbalanced word form, height is a
noun, weight is a gerund
•€On subsequent visits, impressions for full •€On subsequent visits, impressions for full
upper and lower dentures were made, upper and lower dentures were made,
bite registered and complete upper and bite registration was taken and complete
lower dentures were delivered . upper and lower dentures were delivered
Explanation: Passive form required for all verbs
•€She diagnosed with hyperthyroidism in •€She was diagnosed with
1997, hypertension in 2003 and hyperthyroidism in 1997,
Glaucoma since 2004. hypertension in 2003 and
Explanation: Time markers need to be balanced. Glaucoma in 2004.
•€She has had hyperthyroidism since 1997,
hypertension since 2003 and
Glaucoma since 2004.
•€During hospitalization, IV fluids were •€During hospitalization, IV fluids were
commenced and used a transdermal commencedand a transdermal patch was
patch for her pain. used for her pain.
Explanation: Passive form required for all verbs
 •€Further examination revealed dry mouth, •€Further examination revealed dry
dentures were worn out on occlusal mouth. In addition, her dentures were
surfaces and a heavy calculus deposit worn out on occlusal surfaces and a
was seen on the dentures. heavy calculus deposit was seen on the
Explanation: In example 1, by adding in dentures.
addition, you can change the structure and keep •€Further examination revealed dry
the sentence balanced. In example 2 the sentence mouth, worn out dentures on occlusal
is balanced as the verbs have been replaced with surfaces and heavy calculus deposits on
noun phrases. the dentures.
•€She is feeling loneliness and isolated due •€She is suffering
to losing her social contacts from loneliness and isolation due to
Explanation: Loneliness is a noun whereas losing her social contacts. (nouns)
isolated in an adjective so the word forms are not •€She is feeling lonely and isolated due to
balanced. losing her social contacts. (adjectives)
Cohesion
Useful signal markers

Letter Signal Marker Example Sentence

a. • ___ as well • She suffers from oedema as well as bladder incontinence
as__ and only tolerates fluids.
• as a result • This child was admitted with Acute Meningoencephalitis as a
of result of a complication following Mumps.
• Let me inform you that that the patient has proven to be
• as a result uncooperative during his dental treatments. As a result, I
would recommend the treatments be carried out with a
general anaesthetic.
• On vaginal examination cervical excitation was noted along
• along with with tenderness in the right fornix.
• She looked very anxious and was having trouble
• apart from sleeping. Apart from this, no abnormalities were found on
this rectal, cardiovascular and respiratory examinations.
• at that time • Initially, I saw the patient six months ago when she
complained of constipation. At that time, her physical
examination was normal.
b. • besides that • The patient has smoked 40 cigarettes a day for 25-30
• because of years. Besides that he has type 2 diabetes.
this • He smokes 20 cigarettes and drinks 2 beers every
• based on day. Because of this, he has been told to cease smoking and
to reduce alcohol.
• Furthermore, a fine needle aspiration was taken and was
investigated. Based on that, I suggest the dog has developed
lymphoma.
c. • • The depth of periodontal pocket was
consequent 3.4mm.Consequently, he has undergone extensive treatment
ly for carious lesions and oral hygiene maintenance.

d. • • During hospitalization, his vital signs have been monitored

during___ and he has been assisted with his showers.
______ • On 15/2/08, she presented complaining of lower abdominal
pain of 1 day duration.
• duration • Despite various dental treatments and regular dental
cleaning, his general gum condition is only fair.
• despite
f. • for this • Mr. Fox's blood pressure was elevated and he was
reason overweight. For this reason the patient was advised to do
exercise and follow a healthy diet.
h. • hence • The carious lesions on 65 are reasonably deep and hence the
tooth has to be extracted.
• however
• The patient regularly visits the dentist and her oral hygiene
status is good.However, her gums are inflamed.
i. • in terms of • In terms of her medical history, she has mild hypertension
___ and a 12 year history of diverticulitis.
• I have prescribed agleam in order to reduced anxiety.

• in order to • Regarding the medical history, Alfie had a history of thumb

• in addition sucking until the age of 5. In addition, he is epileptic and
uses dylantin to control the attacks.
• in the • I have planned to review him in two months to monitor his
meantime blood pressure and smoking reduction. In the meantime, I
believe he needs urological assessment.
• in case of • In case of any irritation, redness or swelling of the skin,
discontinue the treatment and consult your doctor
immediately
m. • may I • May I remind you that both the teeth will require root canal
remind you treatment and crown.
that…. • My main concern is that the patient is reluctant to breastfeed
• my main and confident in caring for her baby.
concern is
that…….
n. • It • It should be noted that they may have a problem with
should be communicating in English as they understand limited
noted English.
o. • over…… • Over the past week, she has remained free from severe pain
and has been tolerating a fluid diet.
• She first presented to me on 3.7.06 with several episodes of
heart flutter over the previous few weeks.
• on review • On review today, the patient has reduced smoking to 10
today, cigarettes a day, attended gym twice a week and lost 7kg so
far.
p. • please note • Please note, he has an allergic reaction to nuts.

r. • regarding • Regarding his medical history, Jordan suffers from eczema

and asthma for which he receives treatment twice a year.
• Regrettably, she complains of mild constipation and
• regrettably weakness.
• Recently, she has been prescribed Karvea 150mg and
• recently Oroxine 0.1mg per day, Timoptol Eye Drops 0.5% twice a
day and Normison 10mg as required.
s. • since then • His urinalysis and examination were normal except obesity
and borderline hypertension. Since then, he has been doing
regular exercise and has managed to lose 8kg of weight
t. • therefore • Her vital signs were normal, but she was overweight (85
• the reason kg). Therefore she was advised to reduce weight and do
for exercise.
• The reason for the referral is to consider a possible prostate
biopsy regarding the patient’s condition.
 u. • up until • Up until now, Mr. Hutton has lead a very unhealthy life.
now, • Unfortunately, she is not expected to survive more than 3
• months.
unfortunate
ly
w. • with regard • I am writing with regard to this patient, a 57 year-old
to married man who is under our care with the diagnosis of
myasthenia gravis.

Example Cohesive Paragraphs

Doctors
Initially, I saw Mr. Jones last month when he came for check-up. At this time his blood pressure
showed a mild elevation (165/90).Also his weight was above the normal limit (85 kg while his height
is 173 cm). However, the cardiovascular examination and the urinalysis were normal. Therefore I
advised him to lose weight, to stop smoking cigarettes and to come for a review visit within one
month. A prostate specific antigen test was requested to be done before the next visit.

Dentists
Initial examination on 20/ 02/ 2008 revealed that 54 has a temporary filling with a cavity extending
through the furcation. Based on the bitewing radiological findings, I advised both 54 and 65 be
extracted along with the construction of a space maintainer. Moreover I advised the filling of carious
55 and fissure sealant for all 6’s. In my view, general anaesthesia is the proper sedation as the patient
is known to be uncooperative in a dentist chair.

Nurses
When admitted to this hospital, Mr. Jagger complained of haemetemesis, anorexia, dizziness
associated with weight loss and anaemia. He also was suffering from severe epigastric pain after
meals. Therefore, his stool was examined and an endoscopy has been performed.
 Medical Terminology
The medical case notes for the OET exam often contain abbreviations, medical
acronyms and technical language. The task for the writer is to expand these
into full words and sentences. There are 3 reasons why this is important.
1. As the OET is a test of English, you need to demonstrate your
ability to transfer technical language in the case notes into standard
English.

2. For some letters you are may have to write to someone who is
not a health professional such as a social worker or family member.

3. A referral letter is not a report so the standard conventions of

letter writing require a formal style which includes using complete
words and sentences.
Handy Hint: It is a test of English not Latin, so where possible avoid
the use of Latin based acronyms and words.

Here is a list of common abbreviations used in Australia.

Acronym/ Full Expression Acronym/Short Full Expression

Short Form Form
Abdo Abdomen mane in the morning
AC before meals min minute
ADL activities of daily living NAD no abnormality detected
& and nocte in the evening
BD/bid 2 times a day OPG orthopantomogram
BP blood pressure P/PR Pulse/Pulse Rate
BW x-rays bite wing x-rays PMH past medical history
C/O complains of PRN as required
cap capsule QID 4 times a day
DOB Date of Birth R right
ECG electrocardiograph tab tablet
F/- fluoride application sid once a day
FBC full Blood Count TDS/tid 3 times a day
FTA failed to Attend w/o without
IV intravenous y/yrs year
h hour ? rheumatic fever possibility of something
hx history 6/h 6 hourly
L left + positive
lab laboratory 3/12 3 months
Exceptions to this rule include abbreviations of measurement.
Therefore it is acceptable to use the following in short form:

Acronym/Short Full Expression Acronym/Short Full Expression

Form Form
cm centimeter ml millilitre
g gram mg milligram
kg kilogram mm hg milligram of mercury

Common Errors

Incorrect Correct
• Her current medications include sid • Her current medications include a daily
Metformin 500 mg. mane and nocte, dose of Metformin 500 mg. in the
Glycosamine 5mg.mane and morning and at night, Glycosamine
Candesartan 10mg. nocte. 5mg.in the morning and Candesartan
10mg. at night.
• After discharge from hospital, • After discharge from hospital, Mrs.Jones
Mrs.Jones has been told to take has been told to take Aperients when
Aperients (PRN) and Aldomet (250 required and Aldomet twice a day.
mg bid).
• I treated Claudia with • I treated Claudia with prednisolone
prednisolone5mg 1t/sid for seven 5mg tablet once a dayfor seven days.
days.
• On examination, there was • On examination, there was tenderness
tenderness and rebound tenderness and rebound tenderness over the right
over the R. iliac fossa. iliac fossa.
• I am writing to refer Mrs. Wilson, a • I am writing to refer Mrs. Wilson, a 45-
45yr old woman who is suffering year-old woman who is suffering from
from signs and symptoms signs and symptoms suggestive of
suggestive of advanced English. advanced English.
• She presented to me yesterday • She presented to me yesterday evening
evening with abdominal pain mostly with abdominal pain mostly in the left
in the left iliac fossa which had been iliac fossa which had been present for the
present for the last 24 hrs. last 24 hours.
• Her mother died of MI • Her mother died of myocardial infarction
 • On examination she was found to • On examination she was found to have a
have PR 88/min pulse rate of 88 beats per minute.

• On examination she was found to have a

pulse of 88.
• Mr Duane Eddy 57/m is an a urgent • Mr Duane Eddy, a 57 year old male is an
referral regarding an ulcer in R. a urgent referral regarding an ulcer in
lateral border of tongue. the right lateral border of tongue
• I would appreciate if you could • I would appreciate if you could inform
inform me about her treatment & me about her treatment and progress over
progress over the next few days. the next few days.
• The patient was discharged on Dec. • The patient was discharged
30 2009. on December 30 2009.

• The patient was discharged on 30/12/09.

• Lab work and review was planned • Laboratory work and review was planned
for the next morning. for the next morning.

Referring to a Patient
There are certain conventions which need to be followed when referring to a
patient in a formal letter. This worksheet will explain what you need to know so
that you can conform to these conventions.

The basic rules regarding titles are as follows:

• Mr. is used for adult men, married or single

• Mrs. is used for married women including widows

• Ms. is used to refer to both married or unmarried women

• Miss is used for young girls or unmarried women

• Master is used for young boys, but is rare nowadays as it has become old
fashioned. It is still commonly used on an envelope, but not in the body of
the letter.
nb Both miss & master are not abbreviations so no punctuation is required.

Handy Tip 1: Definitely do not use titles with first names only, i.e Mr Thomas or
Mrs. Carol as this is not acceptable. See below for correct usage.
These titles can be used in the following ways
• I am writing to refer Mr. Hacker (standard)

• I am writing to refer Mr. Thomas Hacker (very formal, usually used above
the address or after Re: but not on the body of the letter.)

• I am writing to refer Thomas (informal and commonly used for children)

• I am writing to refer this patient (commonly used in the opening sentence

if patient's name has been mentioned above as in Re: Mr. Thomas Hacker)

Question: When and how often should I use the patient's name in the
letter?
Answer: The standard way is to write the patient's name in full below the opening
saluation. Then, use the patient's name once per paragraph as illustrated
below ,after which you can use pronouns. Also, be consistent in how you refer to
the patient. Do not mix up your use of first names and surnames in the letter as
this will only confuse the reader.

Handy Tip 2: There is no need to write the patient's name out in full in the
introduction if you have stated it below the salutation i.e Re: Mrs. Carol Brady as
it is very clear who you are writing about. In such cases use "this patient" or title
and surname "Mrs. Brady". If you do this you will be following standard
conventions.

Example(Le*er

31 July 2009

The Director
Redeemer Palliative Care Hospital
32 Nelson Drive
St Lucia
Queensland, 4050

Dear Sir/Madam,

Re: Mrs. Carol Brady

DOB 4 February 1968

I am writing to refer this patient, a 42 year old married woman who was
diagnosed with stage 4 ovarian cancer on 22 May 2009. I would appreciate it if
you could provide respite care for her.
I have been supporting Mrs. Brady and her family for the past 2
months,and she is on palliative care and now only expected to live for four
months. Her husband Mr. Mike Brady is her primary carer,and he has reduced his
work hours to look after her and their children aged 10 and 12. He usually feels
that he is exhausted, emotionally stressed and isolated because he finds it
difficult to cope with all the work at home.

Mrs. Brady is depressed and withdrawn and she does want any visitors. In
addition, she has not been eating much recently. Regarding
medication, she takes oxycontin and stemitel twice daily and is on a regular
panadol. However, her pain is still increasing.

Could you please do a reassessment of Mrs. Brady’s pain medication as it may

need to be increased. Thank you for looking afterthis patient and please do not
hesitate to contact me if you have any further questions.

Yours sincerely,

Community Nurse

Common(Mistakes

Mr.$Langer$is$an$only$child. Alfie$is$an$only$child.
Explana5on:$Mr.$is$only$used$for$adult$men,$so$if$the$
pa5ent$is$a$child$you$should$use$their$first$name.
Thank$you$for$seeing$my$pa5ent,$Master$Alfie$Langer,$a$7$ Thank$you$for$seeing$my$pa5ent,$Alfie$
year$old$boy. Langer,$a$7$year$old$boy.
Explana5on:$Master$is$somewhat$old$fashioned$and$does$
not$sound$"familiar"$if$used$in$the$body$of$the$leDer.
Mr.$Peter,$a$23$year$old$young$man,$presented$at$my$ Mr$Holmes,$a$23$year$old$young$man,$
surgery$today$complaining$of$painful$wisdom$teeth. presented$at$my$surgery$today$
Explana5on:$You$can$not$use$5tles$with$first$names$only. complaining$of$painful$wisdom$teeth.
I$am$wri5ng$to$refer$Miss.$Green$for$surgical$assessment. I$am$wri5ng$to$refer$Miss$Green$for$
Explana5on:$Miss$is$not$an$abbrevia5on$so$no$ surgical$assessment.
punctua5on$required.
Dear$Dr., Dear$Doctor,
I$am$wri5ng$this$leDer.... I$am$wri5ng$this$leDer....
Explana5on:$Do$not$use$short$forms$without$the$
surname$of$the$person.
 Informal & Casual Expressions
The written language of English is different to the spoken language in that it is
quite formal whereas the spoken form is more casual. If spoken language
expressions are used in formal letters it affects the “tone and register” of the
letter. Therefore, it is important to maintain a formal tone and use standard
expressions. Below is a list of inappropriate casual expressions with more formal
appropriate expressions.

Example Words

Casua Form Casua Form Casua Form Casua Form Casua Form Casua Form
l al l( al l al l al l al l al
asks$ reque think believ get beca so very but howe kids childr
for sts e me ver en
say state get receiv got beco about regar really greatl sad depre
e me ding y ssed
said state got receiv So There a$bit slight kid child 5ll un5l
d ed fore ly
like inclu like such$ don't$ do$ Than Than kids childr lots a$lot$
de as not ks kQyou en of

Example Sentences

Inappropriate(Casual(or(Spoken(Expression Appropriate(Formal(Expression
• She$refuses$to$eat$solids$and$prefers$fluids$ • She$refuses$to$eat$solids$and$prefers$
only$like$apple$juice$and$lemonade. fluids$such$as$apple$juice$and$lemonade.

• There$are$several$measures$which$can$be$ • There$are$several$measures$which$can$be$
taken$to$reduce$the$risk$of$infec5on$like$ taken$to$reduce$the$risk$of$
taking$a$shower$in$morning,$using$ infec5on$including$taking$a$shower$in$
separate$towel$for$everyone,$changing$ morning,$using$separate$towel$for$
underwear$and$bed$sheets$regularly,$ everyone,$changing$underwear$and$bed$
vacuuming$carpets,$keeping$the$nails$ sheets$regularly,$vacuuming$carpets,$
short$and$washing$hand$thoroughly. keeping$the$nails$short$and$washing$hand$
thoroughly.
• She$was$given$general$advise$for$soTening$
her$stool,like$changing$her$dietary$habit$ • She$was$given$her$general$advise$for$
but$she$was$non$compliant. soTening$her$stoolsuch$as$changing$her$
dietary$habit$but$she$was$non$compliant.
Explana5on:$Like%is$a$casual$expression,$and$the$
two$commonly$used$formal$expressions$with$the$
same$meaning$are%such%as%&%including.
 • Thanks$for$seeing$Mr.$Brown. • Thank$you$for$seeing$Mr.$Brown.

• Thanks$for$arranging$a$home$visit$for$this$ • Thank$you$for$arranging$a$home$visit$for$
pa5ent.$If$you$have$any$further$ques5ons,$ this$pa5ent.$If$you$have$any$further$
please$feel$free$to$ask$me. ques5ons,$please$be$free$to$ask$me.
Explana5on:$Thanks$is$a$casual$expression$and$
should$be$wriDen$in$full.
• In$view$of$the$above$signs$and$symptoms$ • In$view$of$the$above$signs$and$symptoms$
I$think$she$is$suffering$from$ I$believe$she$is$suffering$from$
schizophrenia. schizophrenia

• The$pa5ent's$family$is$thinking$about$a$ • The$pa5ent's$family$is$considering$a$
reduc5on$in$her$medica5on. reduc5on$in$her$medica5on.
Explana5on:%think%is$informal$and$preferable$
expression$is$eitherbelieve%or%consider,$
depending$on$the$context.
• I$would$really$appreciate$your$aDen5on$ • I$would$very$much$appreciate$your$
regarding$further$management$of$this$ aDen5on$regarding$further$management$
pa5ent. of$this$pa5ent.
Explana5on:$Really$is$spoken$language$and$ • I$would$greatly$appreciate$your$aDen5on$
should$be$avoided$in$formal$wri5ng. regarding$further$management$of$this$
pa5ent.
• About$his$dietary$habits,$he$eats$a$large$ • Regarding$his$dietary$habits,$he$eats$a$
amount$of$oily$and$sweet$food. large$amount$of$oily$and$sweet$food.

• If$you$require$any$other$informa5on$ • If$you$require$any$other$
about$her$condi5on,$please$do$not$ informa5on$regarding$her$condi5on,$
hesitate$to$contact$me. please$do$not$hesitate$to$contact$me.
Explana5on:$About$is$a$casual$expression,$
regarding$is$more$suitable.$Lots%of$is$also$casual.$
“A$large$amount$of”$is$more$formal.
• She$had$lots$of$pain. • She$had$a$lot$of$pain.

• He$eats$lots$of$oily$food. • He$eats$large$amounts$of$oily$food.
Explana5on:Lots$is$a$spoken$expression
• There$was$nothing$significant$in$his$social$ • There$were$no$significant$findings$in$his$
history. social$history.
Explana5on:$Nothing$is$more$commonly$a$
spoken$expression$which$is$not$suitable$for$
wri5ng.
 • Please$do$not$hesitate$to$contact$me$if$u$ • Please$do$not$hesitate$to$contact$me$
need$addi5onal$informa5on. if%you$need$addi5onal$informa5on.
Explana5on:$Definitely$no$text%or%SMS%
language%in$formal$leDers.$Replace$with:$you
• She$has$got$maternal$postpartum$ • She$has$had$maternal$postpartum$
haemorrhage$of$800mls. haemorrhage$of$800mls.

• Mr$O’$Riley$got$an$appointment$for$a$ • Mr$O’$Riley$has$an$appointment$for$a$
follow$up$visit$with$his$general$ follow$up$visit$with$his$general$
prac55oner,$Dr.$Avril$Jensen. prac55oner,$Dr.$Avril$Jensen.

• The$mother$got$sick$for$a$few$days. • The$mother$became$sick$for$a$few$days
Explana5on:$Got/Get$are$casual$expressions$and$
should$generally$be$avoided$in$formal$leDers.
• Should$you$have$any$concerns$regarding$ • Should$you$have$any$concerns$
them,$please$do$not$hesitate$to$contact$ regarding$Mary$and$her$child,$please$do$
me. not$hesitate$to$contact$me.
Explana5on:$The$pronoun$them$sounds$casual$
here.$It$is$much$beDer$to$use$the$pa5ent’s$name,$
especially$in$the$final$sentence$of$the$leDer.
• At$the$moment,$she$is$weak$and$ • At$the$moment,$she$is$weak$and$
disorientated$some5mes$but$severe$pain$ disorientated$at$5mes$but$severe$pain$has$
has$been$alleviated. been$alleviated.$
Explana5on:$Some5mes$is$a$casual$expression.$ • 9.At$the$moment,$she$is$weak$and$
More$formal$expressions$include:$at%Bmes$or$on% disorientated$on$occasions$but$severe$
occasions pain$has$been$alleviated.
• This$pain$was$exaggerated$to$cold$and$ • This$pain$was$exaggerated$to$hot$and$
hot$things cold$s5muli.
Explana5on:$Things$is$a$casual$expression$and$
should$be$avoided
• A$repeat$vaginal$examina5on$revealed$a$ • A$repeat$vaginal$examina5on$revealed$a$
very$tender$right$vaginal$fornix.$But$her$ very$tender$right$vaginal$
blood$pressure$pulse$is$within$normal$ fornix.$However,$her$blood$pressure$
range. pulse$is$within$normal$range.
Explana5on:$It$is$not$good$English$to$begin$a$
sentence$with$the$conjunc5on$but$In$this$case$
use$However,$as$it$is$more$formal
 • Her$temperature$and$blood$pressure$ • Her$temperature$and$blood$pressure$
were$normal$while$pulse$was$elevated$at$ were$normal$while$pulse$was$elevated$at$
88.$So$I$recommended$that$she$return$ 88.$Therefore,$I$recommended$that$she$
today$for$a$blood$test$and$reassessment. return$today$for$a$blood$test$and$
reassessment.
Explanation: So is a casual word, you can use
it within a sentence, but not to start a
sentence in formal writing. Replace
with: Therefore,
• There$was$evidence$of$poor$oral$hygiene,$ • There$was$evidence$of$poor$oral$hygiene,$
carious$lesions$and$ac5ve$periodontal$ carious$lesions$and$ac5ve$periodontal$
disease$too. disease$as$well.
Explana5on:$too$is$informal,$a$more$more$formal$
expression$is$as%well.
• Her$husband$was$upset$because,$she$was$ • Her$husband$was$upset$because,$she$was$
not$showing$interest$towards$the$kids. not$showing$interest$towards$
the$children.
• Mark's$dad$also$suffers$from$this$
condi5on. • Mark's$father$also$suffers$from$this$
condi5on.
• The$teacher$spoke$to$her$mum$regarding$
the$regular$absences$from$school. • The$teacher$spoke$to$
her$mother$regarding$the$regular$
Explana5on:$kids,%dad,%mum$are$all$spoken$
absences$from$school.
expressions$which$are$inappropriate$in$formal$
leDers.
• She$had$had$termina5on$of$pregnancy$10$ • She$had$had$termina5on$of$pregnancy$10$
years$back. years$ago.

• He$is$a$regular$smoker$and$drinker$with$ • He$is$a$regular$smoker$and$drinker$with$
the$only$relevant$past$history$of$leT$ the$only$relevant$past$history$of$leT$
inguinal$hernia$opera5on$2$years$back. inguinal$hernia$opera5on$2$
yearspreviously.
Explana5on:$Back$is$used$as$a$spoken$expression$
not$a$wriDen$expression.
• He$had$a$habit$of$thumb$sucking$5ll$the$ • He$had$a$habit$of$thumb$sucking$un5l$the$
age$of$5. age$of$5.
Explana5on:$Till$is$casual,$un5l$is$formal
• She$was$so$anxious. • She$was$very$anxious.
Explana5on:$So$is$informal$and$subjec5ve,$
whereas$very$is$more$formal$and$objec5ve.
• Owen$has$big$tonsils. • Owen$has$enlarged$tonsils
Explana5on:$big$is$informal$and$does$not$sound$
professional.
 • I$am$wri5ng$to$request$a$followQup$for$ • I$am$wri5ng$to$request$a$followQup$
this$pa5ent. visit$for$this$pa5ent.

• Examina5on$revealed$that$his$vitals$were$ • Examina5on$revealed$that$his$vital$
stable$and$leT$knee$was$swollen$without$ signs$were$stable$and$leT$knee$was$
effusion. swollen$without$effusion.

• Examina5on$revealed$normal$vitals. • Examina5on$revealed$that$his$vital$
signs$were$normal.
Explana5on:$Vitals$and$follow$up$are$incomplete$
expressions,$commonly$used$in$spoken$English,$
but$not$suitable$for$formal$wri5ng.
• Mrs.$Jones$is$a$widow$who$complained$of$ • Mrs.$Jones$is$a$widow$who$complained$of$
persistent$chest$pain$at$roughly$1.45pm. persistent$chest$pain$
at$approximately%1.45pm.
• Miss$Roberts$started$smoking$around$6$
months$ago. • Miss$Roberts$started$
smoking$approximately$6$months$ago.
Roughly$and$around$are$casual$or$vague$
expressions.
• I$recommend$some$inves5ga5ons$to$rule$ • I$recommend$further$inves5ga5ons$to$
out$cancer. rule$out$cancer.

• I$requested$some$blood$tests. • I$requested$addi5onal%blood$tests.
Explana5on:$Some$is$vague$and$does$not$sound$
professional.
• Her$BMI$was$28$and$all$the$rest$of$the$ • Her$BMI$was$28$and$the$remainder$of$the$
examina5ons$were$normal. examina5ons$were$normal.
Explana5on:$all%the%rest%of%sounds$informal.
• Abdominal$examina5on$revealed$a$small$ • Abdominal$examina5on$revealed$a$small$
right$groin$swelling$that’s$consistent$ right$groin$swellingthat$is%consistent$
with$inguinal$hernia. with$inguinal$hernia.

• Thank$you$for$your$expert$care$and$please$ • Thank$you$for$your$expert$care$and$
don't$hesitate$to$contact$us$if$you$require$ please$do%not%hesitate$to$contact$us$if$you$
further$informa5on. require$further$informa5on.
Explana5on:$It$is$best$to$avoid$contrac5ons$in$
formal$leDers$as$these$are$used$more$in$spoken$
English.$
• In$addi5on,$she$is$just$able$to$tolerate$ • In$addi5on,$she$is$only$able$to$tolerate$
fluids. fluids.

Explana5on:Just$can$sound$informal$at$5mes.$
 Common Mistakes Regarding Physical Description 

Incorrect  Correct 
Advice was given to reduce her 1. Advice was given to reduce weight. 
weight.  2. The patient was advised to reduce
After the verb reduce it is not weight. 
necessary to follow with a pronoun. 3. A reduction of weight was advised. 
Soyou is not required.  Simply say: 
I advised him to reduce weight,
or, you need to reduce weight. 
In addition, she had lost her weight.  1. In addition, she had lost weight.
After the verb lose it is not correct 2. In addition, she has lost a further 11
to follow with a pronoun.  kg of weight over the past 2 months.
3. In addition, the patient’s weight has
significantly reduced from 61 kg to 50
kg over the past 2 months.
He is now obese with a 99kilos 1. He is now obese with a weight of 99
weight and a 170cm height.  kg and a height of 170cm. (noun form)
The use of the correct verb & noun 2. He weighs 99 kg and is 170cm
form and associated grammar is tall. (verb form)
difficult. Refer opposite for correct 3. He weighs 99kg and is 170cm in
usage.  height. (verb form)
1. Today’s examination revealed 1. Today’s examination revealed
multiple missing teeth, various multiple missing teeth, various carious
carious lesions and a lesions and a periodontal pocket
periodontal pocket of depth depth of 4-9mm.
4-9mm.  2. There are several periodontal pockets
2. There are which are about 4’9 mm in depth   or
several  periodental pockets 3. There are several periodontal pockets
with about 4-9 mm in depth. with a depth of  about 4-9 mm.
Correct word order is:  4. His height is 173cm.
Depth of 4-9mm 
Height of 173cm 
Length of 20 m 
Weight of 78kg 
3. His height was 173cm.  Weight
can change but height can not
so don’t use past tense.
 1. He was overweight 85 Kg 1. He was overweight at 85 kg with
with respect to his height respect to his height  of 173 cm. 
173 cm. 
This sentence is a shortened
version similar to the case
notes. It is important to write
in full sentences. 

Difficult Words
The English language is governed by rules. However, there are also many
exceptions to these rules and words which do not follow the normal or expected
pattern are those which often cause problems. Study this list carefully so that you
can improve your grammatical accuracy and knowledge.

Complain Vs Complaint
Complain is a verb

• The patient complained of severe abdominal pain.

Complaint is a noun
• The patient presented with a complaint of severe abdominal pain.
Note 1: Complaint is a countable noun. so it can be used in the plural form or
singular with an article.
Note 2: The two main prepositions used with complain are: complain of &
complain about.
• Mr. Cochrane presented with complaints of nausea, headache and fever.
(plural)

• Mr. Cochrane presented with a complaint of nausea. (singular with article)

Incorrect Correct
• The$pa'ent$complaints$of$chest$pain$and$ • The$pa'ent$complains$of$chest$pain$and$
her$blood$pressure$is$high. her$blood$pressure$is$high.(verb)

• The$pa'ent$presented$with$a$complain$of$ • The$pa'ent$presented$with$a$complaint$
chest$pain. of$chest$pain.(noun)

• The$pa'ent$presented$with$complaint$of$ • The$pa'ent$presented$with$a$complaint$
chest$pain. of$chest$pain.$(ar'cle$required)

• He$presented$to$my$office$on$ • He$presented$to$my$office$on$
23/03/2008$complaining$on$severe$pain$ 23/03/2008$complaining$ofsevere$pain$
associated$with$the$lower$leA$first$molar. associated$with$the$lower$leA$first$molar.
 Suggest & Recommend Vs Advise

Suggest, recommend and advise are all words commonly used in referral letters
to report information were given to the patient. However their rules of use differ
and result in errors. Here are some examples of their correct and incorrect
usage.

Incorrect Correct
• I$have$suggested$him$to$see$you$next$ • I$suggested$(that)$he$see$you$next$week.
week.
• I$advised$him$to$see$you$next$week
• I$suggested$her$to$return$in$morning$as$
she$required$further$blood$test$and$ • I$suggested$(that)$she$return$in$morning$
assessment. as$she$required$further$blood$test$and$
assessment.
• I$recommended$him$to$rest$for$3$days.
• I$advised$her$to$return$in$morning$as$she$
Explana'on:The$words$suggest$&$recommend$ required$further$blood$test$and$
cannot$be$followed$by$an$object$pronoun$such$as$ assessment.
him/her$whereas$advise$can.
• I$recommended$(that)$he$rest$for$3$days.
Explain Vs Tell

Explain and tell also have different rules which cause confusion

Incorrect Correct
• I$explained$them$that$unsuccessful$ • I$explained$to$them$that$unsuccessful$
concep'on$was$not$unusual$in$their$case. concep'on$was$not$unusual$in$their$case.

• I$have$already$explained$the$couple$the$ • I$told$them$that$unsuccessful$concep'on$
basic$advice$regarding$concep'on. was$not$unusual$in$their$case.
Explana'on:$The$word$explain$cannot$be$ • I$have$already$explained$to$the$couple$
followed$by$a$pronoun$or$noun$without$the$ basic$advice$regarding$concep'on.
preposi'on$to$whereas$tell$can.$
• I$have$already$told$the$couple$basic$
advice$regarding$concep'on.
Advise Vs Advice

Advise is a verb
• We advise patients on how to take their medication.
Advice is a noun
• We give advice or provide advice to patients on how to take their
medication.
Note 1: The noun advice is uncountable so it can not be used in plural form. i.e.
advices is incorrect as is an advice.
• I gave some advice to the patient regarding her medication.
Note 2: The pronunciation is different: advise advice
Incorrect

• • It would be greatly appreciated if you could make a visit to this family

and advice his parents regarding the recommended vaccines for both children. 
• • I am writing to refer this patient to you for an advice regarding the
management of his bilateral inguinal hernia.
• • I$gave$an$advice$to$the$pa'ent$regarding$her$medica'on.
• • I$gave$advices$to$the$pa'ent$regarding$her$medica'on.
• • Please$advice$the$pa'ent$on$how$and$when$to$take$their$medica'on.
•
• Correct

• It would be greatly appreciated if you could make a visit to this family

and advise his parents regarding the recommended vaccines for both children. (verb)
• • I am writing to refer this patient to you for advice regarding the
management of his bilateral inguinal hernia(noun)
• • I$gave$some$advice$to$the$pa'ent$regarding$her$medica'on.(noun)
• • I$gave$advice$to$the$pa'ent$regarding$her$medica'on.(noun)
• • Please$advise$the$pa'ent$on$how$and$when$to$take$their$me

dica'on.$(verb)

Request

Request can be both a verb and noun.

Request as a verb

• The patient requested painkillers. (verb form)

Request as a noun
• The patient made a request for painkillers. (noun form: request+for)

Incorrect Correct
• The$pa'ent$requested$for$new$ • The$pa'ent$requested$new$dentures.$(verb)
dentures.
• The$pa'ent$made$a$request$for$new$
• Ms.$Green$requested$about$IVF$ dentures.$(noun)
treatment.
• Ms.$Green$requested$IVF$treatment.(verb)
Explana'on:$The$common$mistake$is$to$use$the$
verb$form$plus$preposi'on$which$incorrect. • Ms.Green$made$a$request$for$IVF$
treatment.$(noun)
 Affect Vs Effect

Affect is a verb
• The patient has not been affected by the treatment.
Effect is a noun
• The treatment has had no effect.
Note: The pronunciation is the same.
Incorrect Correct
• She$has$also$been$effected$by$glaucoma$ • She$has$also$been$affected$by$glaucoma$
for$the$past$4$years.$ for$the$past$4$years.$(verb)

• The$side$affects$of$this$medica'on$are$ • The$side$effects$of$this$medica'on$are$
unknown. unknown.$(noun)

Widow or Widower

• Widow (noun) refers to a woman whose husband has died and who has not
remarried.

• Widower (noun) refers to a man whose wife has died and who has not
remarried.

• Widowed (adjective) refers either a man or woman whose spouse has died
and has not remarried.
Incorrect Correct
• I$am$wri'ng$to$refer$Mrs.$ • I$am$wri'ng$to$refer$Mrs.$Saunders,$a$58XyearX
Saunders,$a$58XyearXold$ old$widowwho$admiYed$with$pain,$dehydra'on$
widowed$who$admiYed$with$ and$nausea.(noun)
pain,$dehydra'on$and$nausea.
• I$am$wri'ng$to$refer$this$pa'ent$a$58XyearX
• I$am$wri'ng$to$refer$Mr.$ old$widowed$woman$who$admiYed$with$pain,$
Saunders,$a$60XyearXold$widow$ dehydra'on$and$nausea.(adjec've)
who$complained$of$pain$in$his$
upper$right$second$molar. • I$am$wri'ng$to$refer$Mr.$Saunders,$a$60XyearXold$
widower$who$complained$of$pain$in$his$upper$right$
second$molar.(noun)
History

History is always present, never past because you can’t erase it! Therefore you
need to use simple present tense not past tense when using this expression.

Incorrect Correct
• Mrs.$McGowan$had$a$history$of$heart$ • Mrs.$McGowan$has$a$history$of$heart$
palpita'on$of$3$day$dura'on. palpita'on$of$3$day$dura'on.
 Allergy Vs Allergic

Allergy is a countable noun

• Michael has no known allergies.(plural)

• Michael has a peanut allergy. (singular)
Allergic is an adjective
• Michael is allergic to peanuts.
Incorrect Correct
• In$addi'on,$he$is$ • In$addi'on,$he$has$a$known$allergy$to$nuts$for$which$he$was$
known$allergic$to$nuts$ admiYed$to$hospital$with$anaphylaxis$2$years$ago.(noun)
for$which$he$was$
admiYed$to$hospital$ • In$addi'on,$he$is$known$to$be$allergic$to$nuts$for$which$he$
with$anaphylaxis$2$ had$been$admiYed$in$the$hospital$with$anaphylaxis$2$years$
years$ago. ago.(adjec've)

• Regarding$his$medical$ • Regarding$his$medical$history$he$has$an$allergy$to$sulphur$
history$he$is$allergy$to$ containing$drugs.(noun)
sulphur$containing$
• Regarding$his$medical$history$he$is$allergic$to$sulphur$
drugs.
containing$drugs.(adjec've)

Confident Vs Confidence

Confident is an adjective

• The patient is not confident in her ability as a mother.

Confidence is a noun
• The patient lacks confidence in her ability as a mother.
Incorrect Correct
• The$pa'ent$has$not$confident$social$ • The$pa'ent$has$no$confidence$in$social$
situa'ons. situa'ons.$(noun$form)$

• The$pa'ent$is$not$confidence$in$social$ • The$pa'ent$is$not$confident$in$social$
situa'ons. situa'ons.$(adjec've$form)

a few/few & a little/little

Few and a few is used with plural nouns, and little and a little is used with
uncountable nouns. Little and few have negative connotations and are similar
in many to not much/ not many. A little and a few have positive
connotations and are similar in meaning to some. Mixing up these words
therefore will completely change the meaning of the sentence.
 Incorrect Correct
• The$pa'ent$has$reduced$speech$ • The$pa'ent$has$reduced$speech$output$
output$and$a$liYle$eye$contact. and$li#le$eye$contact.(nega've$connota'on$
required$here)
• There$are$few$ways$to$help$iden'fy$
the$possibility$of$threadworms$such$ • There$are$a$few$ways$to$help$iden'fy$the$
as$checking$the$anus$of$your$ possibility$of$threadworms$such$as$checking$
children$at$night$and$frequent$ the$anus$of$your$children$at$night$and$frequent$
scratching. scratching.(posi've$connota'on$required)

during/while

During is followed by a noun

• During hospitalisation the patient made a full recovery.

• The patient had many visitors during his stay in hospital.

While is followed by a phrase or gerund: ____ing
• While in hospital, the patient made a full recovery.

• The patient had many visitors while recovering in hospital.

Incorrect Correct
• He$twisted$his$ankle$during$playing$ • He$twisted$his$ankle$during$a$game$of$
squash$3$months$ago.$ squash$3$months$ago.

• He$twisted$his$ankle$while$playing$
squash$3$months$ago.

following/followed by

Incorrect Correct
• She$was$admiYed$to$our$hospital$ • She$was$admiYed$to$our$hospital$
followed$by$a$collapse$at$home$with$ following$a$collapse$at$home$with$
dehydra'on,nausea$and$severe$pain. dehydra'on,nausea$and$severe$pain.
Incorrect$as$it$means$the$pa'ent$was$admiYed$to$ Correct$as$it$means$the$collapse$occurred$before$
hospital$first,$then$collapsed. being$admiYed$to$hospital.

Years Vs Year 

Incorrect  Correct
I am writing to refer this patient,63 years old man 1. I am writing to refer this
who lives alone. patient, a 63- year- old man,
who lives alone. 
In this sentence there are two mistakes:  2. There are two 63-year-old men
in the waiting room. 
1. the expression is a phrase and therefore
requires an article “a “ to precede the phrase
a 63-year-old man. An article is required
because the noun man is singular. Compare
with: There are two 63-year-old men in the
waiting room. 
2. Years is an adjective in this sentence (it
describes the age of the man) and adjectives
are uncountable.

This patient is 63 year old. This patient is 63 years old. 

In this sentence the word years is a noun preceding an

adjective old. Nouns can be countable so in this case
you must make it plural.
Her father died at 50 year old of bowel cancer  1. 1. Her father died at 50
years of age of bowel cancer 
In this case at is a preposition and needs to be 2. 2.$Her father died at 50
followed by a noun or noun phrase, rather than the years of age of bowel cancer 
adjective” old”. See column on the right for possible 3. 3.$Her$father$died$at the
correct choices. Year is a noun in this case so it should age of 50 of bowel cancer 
4. 4.$Her father died when
be written in plural form. 
he was 50 years old of bowel
cancer. 

Other examples 
1. In addition, he had a habit of thumb 1. In addition, he had a
sucking until age of five years.  habit of thumb sucking until the
2. In addition he had a habit of thumb age of five. 
sucking until he was five years age.  2. In addition, he had a
3. Regarding the medical history, Alfie habit of thumb sucking until he
has a history of thumb sucking until the age of was five years of age. 
5 years,  3. In addition, he had a
habit of thumb sucking until he
was five years old. 
1. In addition she has fillings, crowns, good 1. In addition she has fillings,
dental hygiene and a 13 years old chrome / crowns, good dental hygiene
cobalt removable partial denture. and a 13 year old chrome /
Years is an adjective in this sentence (it describes cobalt removable partial
the age of the denture) and adjectives are denture.
uncountable.
 A to Z of Phrasal Verbs and Useful Vocabulary

Lett Expression Example sentence

er
a • admitted to • The patient was admitted to our hospital in March
. • associated 2008 for the first time.
with
• advised to • Mr. Booth first came to see me on 12/08/08
• advice on complaining of shortness of breath which was
worse when he was lying down. It was associated
• allergies with a tightness in the chest and coughing.
• allergic to • She was advised to return the next day for a
• arrived at blood test and follow up consultation. (verb)
• arrived in • For both children advice on recommended vaccines will be
necessary. (noun)

• She is not on any medication and has no known

allergies.

• Please note, the patient is allergic to penicillin.

• The patient arrived at my surgery in a depressed state.

• The family arrived in Australia in 2007

b • believe • I believe the patient needs urgent assessment
. • borderline and hospital admission
• She was noted to be overweight and
has borderline hypertension.
c • consistent • I am writing to refer Mr. Walker a 40 year old
. with married patient, presenting with signs and
• commence symptoms consistent with prostatic enlargement.
• commence • IV fluids were commenced in order to improve
on hydration.
• Therefore I commenced him on omeprazol 20 mg
daily and strongly advised him to stop smoking
cigarettes and stop drinking alcohol. (active)
• She was commenced on 15gram alepam 1 tablet
nightly for her current anxiety and
sleeplessness. (passive)
• confidence in
• She lacks confidence in caring her baby in terms of breast
feeding and bathing.
d • discharge on • He will be discharged on the 12th of August.
. • deteriorate
• deny • Since 28th of July her condition has
• difficulty in deteriorated with occasional disorientation.
• diagnosed • She denied vomiting and she was vague reporting
with about laxatives.
• diagnosis of • Mr. MacIntosh presented to me with the
complaint of difficulty in passing urine.
• I am writing to refer my patient, Fletcher, a nine
year old Labrador cross dog who isdiagnosed
with high grade lymhoma. (verb)
• Histological results confirmed the diagnosis
of high grade lymphoma.(noun)
e • evidence of • Examination findings revealed evidence of an
. • enclosed enlarged prostate.
• I have enclosed the radiograph for your
convenience.
f • to follow • The patient was advised to follow a low fat diet.
.
h • history • The patient first attended me yesterday
. evening with a one day history of lower
abdominal pain
• Mr. Abrahim has a positive family history of
prostate cancer
i • indicate • The family has indicated that they need an
. interpreter who speaks Farsi or Arabic during
• indicative of follow-up visits with this family.
• However, there was slight swelling in the right
• inconspicuous groin indicative of inguinal hernia

• His family and social history is inconspicious.

k • known • She is a known asthmatic since childhood and is
. on Budesonide inhaler for the same.

m • to make an • I have made an appointment for her through your

. appointment receptionist.

n • on • On examination, her blood pressure was 180/90

. examination mm Hg with a regular pulse of 70 beats per
minute.
o • occasions • Today she presented very anxious and depressed
. as she had noted some blood in her motions on
two separate occasions.

p • provisional • Provisional diagnosis suggests prostate cancer.

. • present at • Mr Gates presented at my clinic yesterday at 7pm
• present to with a complaint of lower back pain.
• Today, he presented to me complaining of a
regular dull ache in the groin.
q • queries • If you have any further queries, please do not
. hesitate to contact me.

r • reveal • Examination today revealed a significantly

. • risk factors increased right groin swelling.
• a routine • His risk factors include: smoking 20 cigarettes per
recovery day, lack of exercise and a strong family history of
• reluctant to hypertension.
• rule out • He has made a routine recovery and his wounds
• remarkable appear to be healing well. 
findings • He is reluctant to seek treatment.

• I believe she needs an urgent assessment to rule

out bipolar disorder

• There were no other remarkable findings.

s • suggestive of • Miss Jones is suffering from the signs and
. • suspicious of symptoms suggestive of ectopic pregnancy.
• I am writing to refer this patient, a 60-year-old
• suffering women,with symptoms suspicious ofbowel
from malignancy
• signs and • Ms.Tylor has been suffering from diabetes and
symptoms she is administering insulin injection by herself.
• He is a 40-year-old man who is suffering from signs
and symptoms suggestive of peritonitis with
perforated gastric ulcer.
t • treated with • He also has been suffering from hypertension
. which has been treated with Atenolol 50 mg
daily.
 u • underlying • I would appreciate your assessment of this girl to
. • under find out whether he has
control any underlyingpsychological problems.
• uneventful • Currently, her pain is under control with
• urgent medication and she is tolerating fluids.
• • Her second pregnancy and delivery
unremarkabl were uneventful.
e • I would appreciate if you could give urgent
• to undergo attention to Mrs. Woods' problem.
treatment/ • Cardiovascular examination was unremarkable and
surgery/an her electrocardiogram was normal.
operation • She underwent colonoscopy three years ago
which was normal. (simple past)
• During hospitalization, the patient has
undergone an electromyogram and X-ray. (present
perfect)
v • vital signs • Her vital signs were normal, but she was
. overweight (85 kg). Therefore she was advised to
reduce weight and do exercise.

w • with a • Mr Gates presented at my clinic yesterday at

. complaint of 7pm with a complaint of lower back pain.

Prepositions
Prepositions are a difficult area of language to fully master as their usage is not
governed by strict rules. The best way to learn prepositions is by regular reading
so that you can slowly absorb and become comfortable with their correct use.
However, it is possible to memorise the correct use of a selection of prepositions
in order to use them accurately in writing the referral letter.

Prepositions of Place

In (used for inside of something): In australia, In hospital, in surgery, in the stomach

On (used for the surface area of something): on the skin, on the ground floor
At (At is used for a place of activity): at work, at home, at the wound site, at the clinic
 Prepositions of Time

In: In is used for On: On is used for At: At is used for Some words
longer periods of days and dates and the time of day and require no
time some time expressions for some expressions preposition
• In November • On Monday • At 6 o'clock • Yesterday
• In Spring • On 20 November • At night • Today
• In 2006 • On Christmas • At lunchtime • Tomorrow
• In the past day • At that time • Last week
• In the future • On his birthday • At the moment • This week
• In the • On review • At the age of • Next week
morning • On examination 45
• In the • On investigation • At birth
afternoon • On presentation
• In her • On two
childhood occasions
• In his twenties

Common Errors

Incorrect Correct
• His father died of cancer during the age • His father died of cancer at the age of
of 50. 50.
• In examination today, the patient was • On examination today, the patient was
anxious and distressed. anxious and distressed.
• Initial examination on today revealed • Initial examination today revealed
inflammed gums. inflammed gums.
• On December 2006, the patient had his • In December 2006, the patient had his
wisdom teeth removed. wisdom teeth removed.
• The patient's family arrived at Australia • The patient's family arrived in Australia
in last year. last year.
 Letter Format

One of the criteria used to assess your writing in the OET exam is Control of
Presentation Features. This criterion assesses the overall presentation of the
letter and includes a lot of the features outside the body of the letter including
• Letter format
• Punctuation
• Capital letters
• Spelling

This worksheet will describe the characteristics of formal medical

correspondence. To do this, the letter has been broken up into 6 parts.

1. Date: The date should be placed at either the top left or top right of the
letter and can be either written in full or as numbers as follows:
o 21/07/10
o July 21, 2010
o 21st July, 2010

2. Address: The address gives the name and address of the person or facility
to whom you are writing. There are some basic conventions which need to be
followed including:
o Capital letters for job titles, names & street names
o Commas not required when the address in separated by lines

Dr. John Howard Dr Ian Hanson Lactation Consultant

1 Wickham Tce Consultant Orthopaedic Surgeon Breast Feeding Support
Spring Hill Riverlea Public Hospital Centre
QLD 4010 Graham Street 68 Main Street
Riverlea Romaville
N.S.W 2068

3.Salutation: If the name of the person is included in the case notes then it
should be used. This can be followed by either a comma or full
colon.
- Dear Dr. Wilson,
- Dear Dr. Wilson:

If the name of person is not mentioned then you can begin with Sir/Madam
o Dear Sir/Madam,
4.Subject: The subject is a place where information such as the name & age
of the patient can be included. This can save you words in the body of the
letter, but be careful not include too much information here, and definitely no
phrases or sentences. Both Re & RE are acceptable.
o Re: Dylan Charles D.O.B.04/12/2009

o RE: Dylan Charles D.O.B.04/12/2009

5.Body: The information in the body of the letter should be divided into
paragraphs, with the standard format for a referral letter being as follows:
o Introduction which includes background information &
purpose of writing or chief complaint in summary form.

o Past medical/social history

o Current condition in detail or discharge plan

o Conclusion, which if time permits, should be specific to the

scenario in then case notes.
Note: OET requires the letters to be between 180~200 words approximately.
The word length is based on the body of the letter only.

6.Closer: The closer is the final part of the letter and should be written one
space below the last line of the body. Only the first word in the closer should
be capitalised and a comma should following the last word.
o Yours sincerely,(standard)

o Sincerely yours,

o Sincerely,

o Yours truly, (American style, but gaining popularity in

Australia)

Note: Yours faithfully, is often recommended as a closer when you don't know
the name of the person to whom you are writing. However, in formal medical
correspondence it is not advised as it puts you in a subservient position.

Sample Letter Format from a Physiotherapist

05/02/2010
Mr. Alex Hinges
Southside Physiotherapy Centre
15 Kings Street
New Hampshire
N.S.W 2240

Dear Mr. Hinges,

Re: Master Peter MacLean
D.O.B. 17/10/1993

Thank you for taking over the care of Peter, a 17-year-old student
who has a history of cystic fibrosis (CF).

Peter was diagnosed with CF when he was born and he needs frequent
admissions due to recurrent lung infections. He lives with his
parents and an elder brother. Peter currently takes Pancrease,
omeprazole and oral hypoglycaemics. His self-management program
includes active cycle breathing (ACB), positive expiratory
pressure (PEP), flutter and posture drainage (PD). Peter’s fitness
is maintained by biking to school.

He was admitted with an exacerbation of his CF on 02/02/2010 with

frequent small and non-productive coughs. Examination revealed a
thin and moderate dehydrated young man with hyperinflated chest.
His temperature was spiking. He had moderately decreased lung
function with blood oxygen saturation (SaO2) of 95%. There were
widespread crackles on auscultation. Peter was treated with
antibiotics intravenously.

Initial physiotherapy consisted of PD, percussion and vibration.

Effective cough techniques were demonstrated.

Peter’s condition has improved and he started gym sessions today.

I have arranged for an appointment with Peter to check the effect
of car fumes when he is biking. I will consider a mask to keep his
airway moisturised if the car fumes impact on his breathing.

Peter will be discharged in 3 days from the medical ward and will
require on going care.

Yours sincerely,

Tania Robinson
Physiotherapist
 Common Errors

Incorrect Correct
30 Dec. 09 30 December 2009
Explanation: The date should be written in full. 30/12/09
To Dr. Blair Howell
Dr. Blair Howell, Admitting Doctor
Admitting doctor 28 George Street
28, George street, Spring Hill
Spring hill, Queensland 4000
Queensland 4000

Explanation:
1. To not required.
2. Commas not required when the address is written top
at the letter because the information is separated lines.
3. Capitals required for job titles
4. Capitals required for street names & suburbs.
Dear Dr Jones Dear Dr. Jones,
Explanation: Comma or full colon required Dear Dr. Jones:
Re: Julie Crosby, 25 yr receptionist, single Re: Julie Crosby, 25 years of
Explanation: Too much information. Best practice is too age
include name and age of patient only. Other information such Re: Julie Crosby, D.O.B
as gender, profession, marital status and so forth can be 21/07/85
included in the opening sentence.
Your's sincerely, Yours sincerely,
Explanation: The possessive form is used before nouns, not
adverbs
Regards, With best regards,
Mary Smith Mary Smith
Charge Nurse Charge Nurse
Explanation: Informal, email style closer
Thanks, Thank you for your assistance
Mary Smith regarding this patient.
Charge Nurse
Explanation: Too casual Yours sincerely,
Mary Smith
Charge Nurse
Hello Dr. Jones, Dear Dr. Jones
Hi Dr. Jones
Explanation: Too casual
Sentence Structure

Adverbial Subject Verb Object/Compliment

Phrase
blank I suspect the patient has developed
ectopic pregnancy.
Comma Unfortunately, I suspect the patient has developed
preferred ectopic pregnancy.
blank Abdominal revealed slight right iliac fossa
examination tenderness.
Comma On slight right iliac was revealed. blank
preferred examination, fossa tenderness
blank Clinical revealed a large mesioincisal
examination of fracture.
hard tissues
Comma On a large mesio- was revealed. blank
preferred examination, incisal fracture
Comma Regarding her she has been asthma for which she
preferred medical suffering from uses a ventolin inhaler.
history,
Comma On review there was
no improvement in her
preferred today, condition.
Comma In terms of his he is a heavy smoker and a
preferred medical heavy to moderate
history, drinker.
Comma Please note, the patient
has an appointment with his
preferred physiotherapist at 10
o'clock on Monday.
Comma In addition, there are composite and amalgam
preferred restorations on several
teeth.
Handy Hint: Do not put a comma between a subject and a verb or a
verb and an object.

The Comma
The comma is the most frequently used punctuation mark within sentences.
Used correctly it allows the writer to separate a group of words or phrase from
other parts of a sentence. This is necessary in order to add useful information
in a sentence. The information can be added at the beginning, the middle or
the end. However if commas are not used or overused, the meaning can be
affected and the flow of information disrupted. By understanding the basic
rules presented in this section you should be able to develop a good
understanding of how and when to use commas in referral letters.

Rules of Usage

1. The Adverbial Phrase: The adverbial phrase can be used in referral

letters to provide information such as a time, place, context, emphasis or
mood in the sentence which is to follow and it is commonly separated by a
comma
• Context: On examination, there was slight tenderness in the right
fornix.
• Date: On today’s visit, the patient was pale and sweaty.
• Emphasis: Please note, the patient is allergic to penicillin.
• Mood: Unfortunately, the patient’s condition has worsened. Note, mood
or comment adverbs, such as unfortunately or regrettably convey the
health professionals concern toward the patient’s condition and are
therefore effective ways of displaying emphathy.
• Contrast: The patient's condition has improved. However, a follow up
visit is required.

2. Appositives: This is a noun or a noun phrase that is placed after another

noun to explain or identify it. It has a very important use in the
introductory sentence of referral letters as follows.
• Mr Smith, an 80 year old widow, was admitted to hospital with
complaints of heart palpitations.
• Thank you for seeing Jordan, a 10 year old boy who presented at my
clinic today with a main concern of pain in tooth 54.
• I am writing to refer Mrs. Bradley, a 42 year old married woman who is
suffering from cancer.

3. Conditional Sentences: These sentences are frequently used in the

conclusion of a referral letter and the rules are as follows:
oUse a comma if the if clause is at the beginning of the sentence.
♣ If you could take over her antenatal care,it would be
much appreciated.
♣ If you have any further questions regarding this patient,
please don’t hesitate to call me.
oDon’t use a comma if the if clause is at the end of the sentence.
♣ It would be greatly appreciated if you could take over her
antenatal care.
♣ Please don’t hesitate to call me if you have any further
questions regarding this patient.
4. Complex sentences:
o Use a comma if the dependent clause is at the beginning of
the sentence.
♣ In case of irritation, redness or swelling, please
consult your doctor.
♣ When the results become available, I will forward
them to you.
♣ Because of her deteriorating condition, the patient
was admitted to hospital.
o Don’t use a comma if the dependent clause is at the end of
the sentence.
♣ Please consult your doctor in case of irritation,
redness or swelling.
♣ I will forward the results to you when they become
available.
♣ The patient was admitted to hospital because of her
deteriorating condition.

5. Comma Splices: A comma splice is two sentences joined together with a

comma, but no conjunction. This is an error as the information must be either
joined with a coordinating conjunction such as and/but/or or a new sentence
must be started.
o He does not have any dental experience, he is worried
about the pain.(incorrect)

o He does not have any dental experience and he is worried

about the pain.(correct)

o He does not have any dental experience. Therefore, he is

worried about the pain.(correct)

6. Noun Clauses beginning with that should not be separated by a

comma.
o It is also important to know, that a re-check is organised for
the 31.5.2009 at 10:30 in order to remove the suture.
(incorrect)

o It is also important to know that a re-check is organised for

the 31.5.2009 at 10:30 in order to remove the suture.
(correct)
7. Use commas to separate three or more words, phrases, or clauses
written in a series.The final word does not require a comma and it should
be separated by a conjunction such as and or or
o Mrs. Olsen has a history of hypertension, hypothyroidism,
glaucoma for which she is on regular medication. (incorrect)

o Mrs. Olsen has a history of hypertension,

hypothyroidism and glaucoma which is on regular medication.
(correct)
Common Errors

Incorrect Correct
1. On review today Mr Walker has 1. On review today, Mr Walker has
reduced smoking from 20 to 10 reduced smoking from 20 to 10
cigarettes per day. cigarettes per day.

2. On examination today there was a soft 2. On examination today, there was a soft
fluctuant swelling palpable on the left fluctuant swelling palpable on the left
cheek cheek

3. Regrettably she has problems with 3. Regrettably, she has problems with
breast feeding and caring for the baby. breast feeding and caring for the baby.

4. Please note he has a prosthetic heart 4. Please note, he has a prosthetic heart
valve. valve.
Comma preferred for adverbial phrases. Refer
to rule 1 above.
1. I am writing to refer Mr. Jones a 57 1. I am writing to refer Mr. Jones, a 57
year old man who was admitted to year old man who was admitted to
hospital on the 18th of July, diagnosed hospital on the 18th of July, diagnosed
with myasthenia gravis. with myasthenia gravis.

2. Mr Jones, a 57 year old man was 2. Mr Jones, a 57 year old man, was
admitted to hospital on the 18th of admitted to hospital on the 18th of
July, diagnosed with myasthenia July, diagnosed with myasthenia
gravis. gravis.
Comma required for appositives. Refer to rule
2 above.

Apply the comma rule for conditional

sentences. Refer to rule 3 above.
 Apply the comma rule for complex sentences.
Refer to rule 4 above.
• He has an allergy to nuts, once he was • He has an allergy to
hospitalised for severe anaphylactic nuts and was once hospitalised for
reaction. severe anaphylactic reaction.
Refer to rule 6 above.
• Please note that, Daniel has an allergy • Please note that Daniel has an allergy
to peanuts. to peanuts.
Apply the comma rule for comma splices.
Refer to rule 5 above.
• Mr.Farrah, presented at my surgery • Mr.Farrah presented at my surgery
today complaining of pain radiating today complaining of pain radiating
from his left ear to his front teeth. from his left ear to his front teeth.
Do place a comma between the subject and
verb of a sentence.
• Initial examination revealed, complete • Initial examination revealed complete
edentulous upper and lower jaws with edentulous upper and lower jaws with
healthy soft tissue. healthy soft tissue.

• I am writing to request, visits for this • I am writing to request visits for this
family. family.
Do place a comma between the verb and object
of a sentence.

For more information on comma usage, follow this link.

Capitalisation
Correct use of capitals is an important area to master when writing referral
letters. Study the rules of usage below to ensure you meet the standard
conventions.

Rules of Usage

1. Medications and Diseases

o Capitals are required for proper nouns. Proper nouns include
the brand name of a drug or registered trademark of the
 manufacturer.
♣ Ritalin
♣ Voltaren
♣ Zocor
o The chemical constituent should be written in lower case.
♣ penicillin
♣ amoxicillin
o Names of diseases should always be lower case.
♣ bowel cancer
♣ high blood pressure
♣ diabetes
♣ epilepsy
o Eponyms: Some medical conditions are named after the
person who discovered it. In this case the first word should be
capitalised.
♣ Parkinson’s disease
♣ Bell’s palsy
o Names of medical procedures do not require capitals.
♣ orthopantomogram
♣ x-ray
♣ caesarian section
o Body parts should always be lower case
♣ heart
♣ adrenal gland
♣ knee

2. Proper Nouns: Proper nouns name something specific as in the

examples below. These words must always be capitalised.
o Job titles
♣ The Lactation Consultant, Mater Hospital
♣ The Veterinary Eye Specialist, University of
Queensland
o Institutions
♣ Mary Jones was admitted to Spirit Hospital.
♣ Dr. Bloomfield works at Weller Point Medical Centre.
o Places including addresses
♣ 168 Wickham Terrace, Spring Hill
 ♣ 12 Logan Road, Mt Gravatt
♣ 36 Barmore Street, Holland Park
o Titles when they precede the name of a person
♣ The patient was seen by Doctor Smith.
♣ Nurse Jones is in charge of the patient's care.

3. Common Nouns: Common nouns do not name any specific

institution, place, person or profession. These words do notneed to be
capitalised.
o The patient was admitted to hospital.

o The patient does not have a family doctor.

o Steve is a teacher.

o Yoshiro is a doctor.

o Reza is a dentist.

4. Holidays, months, days of the week all need to be capitalised.

However seasons do not.
o The baby was born on Christmas Day.

o The patient was admitted to hospital on January 12.

o Please come and see me on Wednesday.

o The vaccination will be available in spring.

5. The pronoun "I" must always be capitalised.

o It was I who treated the patient.

6. Capitalise the first word of a salutation and the first word of a

complimentary close.
o Dear Dr. Jameson:

o Yours sincerely,
 Common Errors

Incorrect Correct
• His medical history shows that he is • His medical history shows that he
Epileptic. is epileptic.

• Also, I have given Dycal base on 1.1 • Also, I have given dycal base on 1.1
and dressed it with Glass Ionomer and dressed it withglass ionomer
Cement. cement.

• The patient was diagnosed with Type 2 • The patient was diagnosed with type 2
Diabetes. diabetes.

• Mrs. Marsh has a history of • Mrs. Marsh has a history

Hyperthyroidism, Hypertension and of hyperthyroidism, hypertensionand g
Glaucoma. laucoma.

• The patient is allergic to Penicillin. • The patient is allergic to penicillin.

• The patient suffered from severe • The patient suffered from

Abdominal pain. severe abdominal pain.
Refer to rule 1 above.
• Mr. duane thomson presented at my • Mr. Duane Thomson presented at my
clinic today with the complaint of a clinic today with the complaint of a
broken posterior tooth. broken posterior tooth.

• The director of nursing • The Director of Nursing

• emergency department • Emergency Department

• Mater hospital • Mater Hospital

• 84 Monash road • 84 Monash Road

• The patient was seen by doctor Jones. • The patient was seen by Doctor Jones.
The above words are all proper nouns. Refer
to rule 2 above.
 • As per the General Practitioner’s order, • As per the general practitioner’s order,
we are doing daily home visits and we are doing daily home visits and
wound dressing and also assisting him wound dressing and also assisting him
with his showers. with his showers.

• Please see your Pharmacist for advice. • Please see your pharmacist for advice.

• Ms. Gatsby is a University student. • Ms. Gatsby is a university student.

The above words are all common nouns. Refer
to rule 3 above.
• The patient first visited my surgery in • The patient first visited my surgery
march, 2008. in March, 2008.

• Mrs. Green will be discharged from • Mrs. Green will be discharged from
hospital on wednesday. hospital on Wednesday.

• Symptoms of hay fever are worse in • Symptoms of hay fever are worse
Spring. in spring.
Refer to rule 4 above.
• The patient requested that i prescribe • The patient requested that I prescribe
antibiotics for the virus. antibiotics for the virus.
Refer to rule 5 above.
• dear Dr. Roberts: • Dear Dr. Roberts:

• yours sincerely, • Yours sincerely,

Refer to rule 6 above.
Model Letter 1: David Taylor

07/11/10

Dr. James Brown

1238 Gympie Rd
Chermside, 4352

Dear Dr. Brown,

Re: David Taylor

Thank you for seeing this patient, a 38-year-old male who has a damaged
cartilage in the left knee joint. He is self-employed as a landscape gardener, and
is married with 3 children.

Mr. Taylor first presented on 12 August 2010 complaining of pain and swelling in
the left knee joint associated with difficulty in strengthening the joint. He initially
twisted this joint in a game of tennis 6 months previously, experiencing pain and
swelling which had responded to painkillers. Examination revealed a slightly
swollen joint and there was a tender spot in the medial aspect of the joint.
Voltarin 50mg twice daily was prescribed.

Despite this treatment, he developed intermittent pain and swelling of the joint.
The x-ray showed no evidence of osteoarthritis. However, the range and power
including passive and active movements was impaired. An MRI scan was
therefore ordered and revealed a damaged medial cartilage.

Today, the pain was mild but the swelling has not reduced. Mr Taylor is keen to
resolve the issue as it is affecting his ability to work and support his family.

In view of the above I believe he needs an arthroscopy to remove the damaged

cartilage to prevent osteoarthritis in the future.

Yours sincerely,

Dr. Peter Perfect

Word Count: 200 words
 Task 2 Model Letter: Tom Cribb

June 1 2010

Dr. B. Comber
Urologist
Southport Hospital
Gold Coast

Dear Doctor,

Re: Mr. Tom Cribb

DOB: 23/05/1982

I am writing to refer Mr. Cribb, a married and unemployed male who has a renal
mass.

Mr. Cribb first came to see me on the 12/05/10 complaining of severe pain in the
right lower abdomen which was radiating to the groin. It was not associated with
urinary or gastrointestinal symptoms, trauma or fever. His vital signs were
normal and his lower abdomen was mildly tender. He was prescribed diclofenac
suppositories 50mg twice a day for 5 days. He was adviced to drink fluids and
walk regularly. The IVP report on the 14/05/10 showed an enlarged and ectopic
right kidney, no stones were reported and the UFR had a few red cells. With
regard to his risk factors, he is a smoker and drinks alcohol. His father has
hypertension and his mother died from breast cancer.

On today’s consultation, he complained of right lower abdominal pain of 5 day

duration which was relieved by panadol. His vital signs were normal and a mass
was palpated in the right abdominal area. His right kidney was below the normal
site. The ultrasound showed severe hydronephrosis and a mass attached to the
liver. He was advised to undergo further CT scan investigations.

I would appreciate your assessment to Mr. Cribb’s urologic problem.

Yours sincerely,

GP

Word Count: 209 words

 Task 3 Model Letter: Alison Martin

10/02/10
Dr. Peta Cassimatis
1414 Logan Rd,
Mt Gravatt, 4222

Re: Alison Martin

Dear Doctor,

I am writing to refer Mrs. Martin, a 28-year-old married woman, who is

presenting with symptoms suggestive of schizophrenia.

Mrs Martin has been a patient at my clinic for the last 10 years and has a family
history of schizophrenia. She is a teacher with two children, aged 4 years and 10
months, and lives with her husband’s parents.

She first presented at my clinic on 9 January 2010 complaining of tiredness, a

lack of motivation at work and a low grade fever. On review after ten days, she
did not show any improvement. She displayed symptoms of paranoia and was
suffering from poor sleep, anxiety and frequent headaches. In addition, she was
mildly depressed with little eye contact. Relaxation therapy and counselling were
started and Diazepam 10 mg at night was prescribed based on my provisional
diagnosis of early depression or schizophrenia.

She presented today accompanied by her husband in a depressed state, showing

little eye contact, bizarre behaviour and disorganised speech. Despite my
management, her symptoms have continued to worsen with a 5-day history of
reduced speech output, impaired planning ability as well as some visual
hallucinations and delusions.

In view of the above, I would appreciate your attention to this patient.

Yours sincerely,

Dr. Ivan Henjak

Word Count: 204 words
 Sample Writing Task 1: Darren Walker

Read the cases notes below and complete the writing task which follows

Time allowed: 40 minutes

Today's Date

15.08.09

Patient History
Darren Walker

DOB 05.07.69

Regular patient in your General Practice

09.07. 09

Subjective
Regular check up, Family man, wife, two sons aged 5 and 3
Parents alive - father age 71 diagnosed with prostate cancer 2002.
Mother age 68 hypertension diagnosed 1999.
Smokes 20 cigarettes per day –trying to give up
Works long hours – no regular exercise
Light drinker 2 –3 beers a week

Objective
BP 165/90 P 80 regular
Cardiovascular and respiratory examination normal
Height 173 cm Weight 85kg
Urinalysis normal

Plan
Advise re weight loss, smoking cessation
Review BP in 1 month
Request PSA test before next visit

14.08.09

Subjective
Reduced smoking to 10 per day
Attends gym twice a week, Weight 77 kg
Complains of discomfort urinating

Objective
BP 145/80 P76
DRE hardening and enlargement of prostate
PSA reading 10
Plan
Review BP, smoking reduction in 2 months
Refer to urologist – possible biopsy prostate

Writing Task

Write a referral letter addressed to Dr. David Booker (Urologist) outlining his
condition, 259 Wickham Tce, Brisbane 4001. Ask to be informed of the outcome.

In your answer:

* Expand the relevant case notes into complete sentences

* Do not use note form
* The body of the letter should not be more than 200 words
* Use correct letter format

Sample Model Letter 1

15/08/2008

Dr. David Brooker (Urologist)

The Urology Department
259 Wickham Tce,
Brisbane, 4001

Dear Doctor,

Re: Mr. Darren Walker

I am writing to refer this patient, a 40 year old married man with two sons aged
3 and 5, who requires screening for prostate cancer.

Initial examination on 09/07/09 revealed a strong family history of related illness

as elderly father was diagnosed with prostate cancer and mother was diagnosed
as hypertensive. Mr Walker is a smoker and light drinker. He works long hours
and does not do any regular exercise. His blood pressure was initially 165/90
mmhg and pulse was 80 and regular. He is 173cm tall and his weight, at that
time, was 85 kg. He was advised to reduce weight and stop smoking and a
prostate specific antigen test was requested. There were no other remarkable
findings.

When he came for the next visit on 14/08/2009, Mr Walker had reduced smoking
from 20 to 10 cigarettes per day and was attending gym twice a week. He had
lost 8kg of weight. His blood pressure was improved at 165/90mmhg. However
digital rectal examination revealed an enlarged prostate and the PSA reading was
10.

In view of the above signs and symptoms, I believe he needs further

investigations including a prostate biopsy and surgical management. I would
appreciate your urgent attention for his condition.

Yours sincerely,

Dr.X

Word Length: 205 words

Sample Writing task 2

Read the cases notes below and complete the writing task that follows

Time allowed: 40 minutes

Today's Date

03.07.09

Patient History
Margaret Leon 01 .08. 49

Gender: Female

Regular patient in your General Practice .

14.01.09
Subjective
Wants general check up, single, lives with and takes care of elderly mother.
Father died bowel cancer aged 50.
Had colonoscopy 3 years ago. Clear
Does not smoke or drink

Objective
BP 160/90 PR 70 regular
Ht 152cm
Wt 69 kg
On no medication.
No known allergies.

Assessment
Overweight. Advised on exercise & weight reduction.
Borderline hypertension.
Review in 3 months

25.04.09
Subjective
Feeling better in part due to weight loss

Objective
BP 140/85
PR 70 regular
Ht 152cm
Wt 61 kg

Assessment
Making good progress with weight. Blood pressure within normal range

03.07.09
Subjective
Saw blood in the toilet bowl on two occasions after bowel motions. Depressed and
very anxious. Believes she has bowel cancer. Trouble sleeping.

Objective
BP 180/95 P 88 regular
Ht 152cm Wt 50 kg
Cardiovascular and respiratory examination normal.
Rectal examination shows no obvious abnormalities.

Assessment
Need to investigate for bowel cancer
Refer to gastroenterologist for assessment /colonoscopy.
Prescribe 15 gram Alepam 1 tablet before bed.
Advise patient this is temporary measure to ease current anxiety/sleeplessness.
Review after BP appointment with gastroenterologist

Writing Task

Write a letter addressed to Dr. William Carlson, 1st Floor, Ballow Chambers, 56
Wickham Terrace, Brisbane, 4001 requesting his opinion.

In your answer:

• Expand the relevant case notes into complete sentences

• Do not use note form

• The body of the letter should not be more than 200 words

• Use correct letter format

•
•
•
• etter 2: Margaret Leon
 Sample Model Letter 2
03/07/2009

Dr. William Carlson

First Floor,
Ballow Chamber
56 Wickham Tce,
Brisbane 4001

Dear Doctor Carlson,

Re: Margaret Leon

DOB 01/08/1949

Thank you for seeing my patient, Margaret Leon, who has been very concerned
about blood in her stools. She has seen blood in the toilet bowl on two occasions
after bowel motion. She is very anxious and as well as that depressed because
her father died of bowel cancer and she feels she may have the same condition.

Margaret has otherwise been quite healthy. She does not drink or smoke and is
not taking any medication. She was slightly overweight six months ago with
borderline high blood pressure. At that time I advised her to lose weight which
she did successfully. Three months later, her weight had dropped from 69kg to
61kg and blood pressure was back within normal range.

On presentation today she was distressed because she believes she has bowel
cancer. She has had trouble sleeping and her weight has reduced a further 11
kg. The rectal examination did not show any abnormalities. Her blood pressure
was slightly elevated at 180/95 but her cardiovascular and respiratory
examination was unremarkable. Alepam, one before bed, was prescribed to
control the anxiety and sleeplessness.

I would appreciate it if you could perform a gastroenterology assessment.

Yours sincerely,

Dr X (GP)

Word Length: 194 words

 Sample Writing Task 3: Cathy Jones

Read the cases notes below and complete the writing task that follows

Time allowed: 40 minutes

Today's Date

16.02.09

Patient History

Miss Cathy Jones - 25 year old single woman

Occupation - receptionist
Family history of deep vein thrombosis
On progesterone-only pill (POP) for contraception
No previous pregnancies

15.02.09
Subjective

Presents to GP surgery at 7 pm, after work

Complains of lower abdominal pain since the evening before, worse in right iliac
fossa
Unsure of last menstrual period, has had irregular bleeding since starting POP 2
months ago

New partner for past 2 months

No bladder or bowel symptoms

Objective

Mild right iliac fossa tenderness, no rebound / guarding

Apyrexial, pulse 88, BP 110/70

Vaginal examination - quite tender in right fornix. No masses

Assessment

Non-specific abdo pain

Plan: Asks her to return in morning for blood test and reassessment

16.02.09

Subjective

Pain has worsened overnight. Now severe constant pain.

Some slight vaginal bleeding overnight also.
Felt faint while waiting in reception.
On questioning, has left shoulder-tip pain also.
Objective

Very tender in the right iliac fossa, with guarding and rebound tenderness
Apyrexial, Pulse 96, BP 110/70
On vaginal examination, has cervical excitation and markedly tender in the right
fornix.
Pregnancy test result positive
Urine dipstick clear

Assessment

Suspected ectopic pregnancy

Plan: You ring the on duty Gynaecology Registrar and ask for urgent assessment,
and are instructed to send her to the A&E Department with a referral letter.

Writing Task

You are the GP, Dr Sally Brown. Write Referral letter to the Gynaecology
Registrar at the Mater Hospital, South Brisbane. Ask to be kept informed of the
outcome.

In your answer:

• Expand the relevant case notes into complete sentences

• Do not use note form

• The body of the letter should not be more than 200 words

• Use correct letter format

 Sample Model Letter 3: Cathy Jones

Gynaecology Registrar
A&E Department
Mater Hospital
South Brisbane

Dear Doctor,

Re: Cathy Jones DOB 1.12.83

Thank you for seeing this 25 year old woman who I suspect has an ectopic
pregnancy.

This is her first pregnancy. She presented to the surgery yesterday evening with
vague lower abdominal pain. She started the progesterone-only pill for
contraception two months ago, when she started a new relationship, and has had
some irregular bleeding since then. Therefore she is unsure of her exact last
menstrual period. Yesterday, she was mildly tender only and her observations
were normal.

However, on review this morning her pain had worsened overnight, she is very
tender in the right iliac fossa, with rebound and guarding, and on vaginal
examination there is cervical excitation, and marked tenderness in the right
fornix. Her pregnancy test is positive.

I am concerned that she may have an ectopic pregnancy, and would appreciate
your urgent assessment.

Please keep me informed of the outcome.

Yours sincerely,

Dr Sally Brown (GP)

 Dos & Don’ts
 Below are a list of simple points to remember on the day of your exam.

Do Don’t
Summarise all the information from the case Follow a strict chronological order as your
notes into sections such as: treatment given letter may become too long, difficult to read
and obvious trends, medication, medical and will not focus on the main problem and
history. This will be both easier to write and related factors.
read as well as avoiding repition
Try to write somewhere between 180 and 200 Write over 220 words as it will effect your
words for the body of the letter. This is the overall result. You being tested on your ability
requirement of OET and the assessors are quite to write a clear concise letter, not a long
strict in this area. letter.

Don’t write under 160 words as there may not

be sufficient language to get a B grade.
Omit information which is not directly relevant Try to put all the information from the case
to your task. This is a big trap for many notes into the letter. Your letter will be too
candidates in that they try to write down all long and also poorly organised and difficult to
the information from the task sheet. This does read
not reflect reality.
Expand on all acronyms. For example OPG Overuse acronyms. You are being tested on
should be written asorthopantamogram, BP as you ability to expand on case notes so make
blood pressure and PR as pulse rate & hx as sure you do.
history
Provide a simple clear summary of the Use too much medical jargon. Remember it is
condition so that a lay person could a test of English not Latin!
understand
Spend time reading the case notes and Start writing without planning your letter. You
grouping information which are related such should allow 15 minutes reading case notes
as medication, persistant high blood pressure and planning the letter.
etc etc
Use synonyms so that you can express the Copy directly from the case notes without any
information from the case notes in different changes. You are expected to put the
ways information into your own words.
Allow 5 minutes at the end of the test to proof Submit the letter without checking for basic
read your work and fix up any mistakes mistakes such as grammar/spelling.