Letter Format

1. Date
-The date is usually written day/ month/ year e.g. 14/08/2014
-Leave an empty line after the date.

2. Address
- Use the full name in the address e.g. Dr Rosalind MacQueen.
- Leave an empty line after the address.

3. Salutation
-Write the salutation (Dear...)-
-Use Dr/ Mr/ Ms/ Mrs/ Miss etc. then the family name e.g. Dr MacQueen.
-Do not use the person's first name.
-In modern letters, you do not need a comma after the salutation. If you do use a comma, then
you must remember to use a comma after 'Yours sincerely' too.
-Leave an empty line after the salutation.

4. Reference
-Write the reference Re:
-State the name and age (or DOB:) Of the patient.
-Leave an empty line after the reference.
5. Body
-Write 180 - 200 words..
-There is no ideal number of paragraphs.
-Make sure there is a clear purpose for each new paragraph you begin.
-Leave an empty line after each paragraph.
-Link and support every line you write with the previous one

6. Closing
-"Yours sincerely" is the simplest and most acceptable choice of closing. -Note that only the first
word has a capital letter (Yours sincerely). You can write "Yours faithfully" when you are not
aware of the name Of your reader
-You do not need a comma(,) after the closing but it is best to add a comma if you have used a
comma after the salutation.

7. Name & Title

- At the end Of the letter, you should write your job title e.g. Doctor, General practitioner . You
do not need to write your own name
Types of Letters. We have three types of letters.

I. Referral type - 99% of the time

A. Routine referral- From GP to a specialist
1. Introduction
2. Personal and past medical history paragraph
3. Initial Visits Paragraph
4. Today's visit Paragraph
5. Closing
B. Urgent referral - When you are asked to send the patient to A&E/HospitaI for admission and
urgent treatment.
1. Introduction
2. Today's Visit Paragraph
3. Initial Visits Paragraph
4. Personal History Paragraph (*least important)
5. Closing

2. Transfer type- Transfer of care/ Transfer to another health facility

A. When it's an intradepartmental referral task within the Hospital setting. ( Follow the
same layout as of a referral letter's layout)
B. When sending patient to another place, to rehabilitation center outside of the
Hospital (follow the discharge letter's layout)
3. Discharge Type When you are asked to write a discharge
letter to patient's GP (*most of the time)
1. Introduction
2.Admission/Hospitalization details para
3. Treatment Record/post operative care and Progress Para
4. Today's assessment
5. Personal History (*Note: We don't write patient's personal and past medical history when
writing to patient's own GP)
6. Closing

4. Infamous Update type - When you are asked to update patient's GP or community nurse
on patient's health status following admission to the hospital
1. Introduction
2. Admission Details Paragraph
3. Treatment Record paragraph
4.Today's assessment
5. Closing with further follow-up request
CASENOTES
Case notes # 01

TIME ALLOWED: READING TIME: 5 MINUTE

WRITING TIME: 40 MINUTES

Read the case notes below and complete the writing task which follows.
Name Mrs. Larissa Zaneeta, Age 38-years-old
Family and social history Marketing manager, married, one child (four-year-old boy).
Medical history
Unremarkable. no medications

11/07/05
Complains of tiredness, difficulty sleeping for 2 months due to work stress Plans another child in
12 months, currentty on oral contraceptive pill IOCP)
Appears pale. tired and slightly restless
BP 140/80
No abnormal findings
Assessment: Stress-related anxiety Plan:
advised relaxation techniques, reduce working hours, prescribe sleeping tablets tds
15/08/06
Stopped OCP 4 months earlier, still menstruating , Worried
Sleep still difficult. work stress unchanged, not possible to reduce hours
O/E: Tired-looking, slightly teary
Assessment: Work stress, growing anxiety failure to conceive Plan:
discussed nature of conception — takes time, patience discussed frequency sexual intercourse
discussed methods — temperature / cycle.

18/01/07
Expressed anxiety re failure to conceive, says she's "too old" sleep still a problem
crying. pale, fidgety
Vital signs / general exam NAD
Pelvic exam, pap smear
Assessment: as per previous consultation
1-2 Valium b.d.
Suggested she re-present next week accompanied by husband.

25/01/07
Mr. Zaneeta very supportive of having another child, No erectile dysfunction, libido normal
Mrs. Zaneeta unchanged, Mr. Zaneeta normal
Plan: Check Mr. Zaneeta’s sperm count
02/02/07
Sperm count normal
Plan: Refer for specialist advice

Writing Task
Using the information in the case notes, Write a letter of referral to Dr Elvira Sterinberg, a
Gynecologist at 123 Church St, Richmond 3121.

In your answer:
Expand the relevant case notes into complete sentences
• Do not use note form
• Use correct letter format
Case notes # 02
TIME ALLOWED: READING TIME: 5 MINUTES WRITING
TIME: 40 MINUTES

Read the case notes below and complete the writing task which follows.
notes:

Today's Date 07/11/10

Patient History
Mr David Taylor, 38 years old, married, 3 children
Landscape Gardener, Runs own business, No personal injury insurance, Active, enjoys sports2.
Drinks 1-2 beers a day. More on weekends. Smokes 20-30 cigarettes/day
P.M.H-Left Inguinal Hernia Operation 2008

12/08/10
Subjective: C/o left knee joint pain and swelling, difficulty in strengthening the leg.
Has history of twisting L/K joint 6 months ago in a game of tennis.
At that time the joint was painful and swollen and responded to pain killers.
Finds injury is inhibiting his ability to work productively.
Worried as needs regular income to support family and home repayments.
Objective: Has limp, slightly swollen L/K joint, tender spot on medial aspect of the joint and no
effusion.
Temperature- normal
BP 120/80
Pulse rate -78/min
Investigation - X ray knee joint
Management
Voltarin 50 mg bid for 1/52 Advise to reduce smoking
Review if no improvement.

25/08/2010
Subjective
Had experienced intermittent attacks of pain and swelling of the L/K joint No fever
Unable to complete all aspects of his work and as a result income reduced Reduced smoking
15/day

Objective:
Swelling + No effusion
Tender on the inner-aspect of the L/K joint Flexion, extension — normal
Impaired range of power - passive & active
Diagnosis ? Injury of medial cartilage Investigation — ordered MRI
Management
Voltarin 50mg bid for I week
Review after 1 week with investigations
07/11/10
Subjective
Limp still present
Patient anxious as has been unable to maintain full time work.
Desperate to resolve the problem Weight increase of 5kg
Objective
Pain decreased, swelling — no change
No new complications
MRI report — damaged medial cartilage
Management Plan
Refer to an orthopaedic surgeon, Dr James Brown to remove damaged cartilage in order to
prevent future osteoporosis. You have contacted Dr Brown's receptionist and you have arranged
an appointment for Mr Taylor at 8am on 21/11/10

Writing Task:
You are the GP, Dr Peter Perfect. Write a referral letter to Orthopaedic Surgeon, Dr. James
Brown: 1238 Gympie Road, Chermside, 4352.
In your answer:
Expand the relevant case notes into complete sentences
Do not use note form
Case notes # 03

Read the case notes Below and complete me writing task given Below.

Today's Date 16.02.13

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
15/02/2013
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 abdominal pain
Plan: Advice her to return in morning for blood test and reassessment
16.02.13
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 Gynecology Registrar at the Spirit
Hospital, South Brisbane. Ask to be kept informed of the outcome.
Read the case notes below
Case notes # 04

Today's Date 21/01/12

Patient History
Brendan cross, Male , DOB: 25/12/2003
Has a sister 6 years, brother 3 years
Mother — housewife
Father — Naval Officer currently on active duty in Indonesia
P.M.H- NAD
Brendan is on 50th percentile for height & weight
Allergy to nuts — hospitalised with anaphylaxis 2 years ago following exposure to peanuts

14/01/12
Subjective: Fever, sore throat, lethargy, many crying spells — all for 3 days.

Objective
Temperature - 39.80 C
Enlarged tonsils with exudate , Enlarged cervical L.N.
CVS – NL, RR- NL
Probable Diagnosis: Tonsillitis (bacterial)
Management: Oral Penicillin 250mg 6/h, 7days + Paracetamol as required. Review after 5days if
no improvement.
19/01/2012
Subjective
Mother concerned — sleepless nights, difficulty coping with husband away — mother-in-law
coming to help.
Brendan not eating complaining of fever, right knee joint pain, tiredness, lethargy —for 2 days
Objective
Temperature - 39.2 0 C, Hypertrophied tonsils Cervical limp node — NL
Swollen R. Knee Joint No effusion, Mid systolic murmur, RR - normal
Investigation
ECG, FBC, ASOT ordered
Treatment
Brufen 100mg tds, review in 2 days with investigation reports

21/1/12
No change of symptoms
ECG — prolonged P-R interval
ESR — increased
ASOT — Increased
Diagnosis
? Rheumatic fever
Plan:
Contact Spirit Paediatric Centre to arrange an urgent appointment
with Dr Alison Grey, Paediatric Consultant requesting further
investigation and treatment.

Writing Task:
You are GP, Dr Joseph Watkins, Greenslopes Medical Clinic, 294 Logan Rd, Greenslopes, Brisbane
4122. Write a referral letter to Dr Alison Grey, Mater Paediatric Centre, Vulture Street, Brisbane
4101.
In your answer:
Expand the relevant case notes into complete sentences
Do not use note form
Use correct letter format
The body of your letter should be approximately 200 words. Use correct letter format.
Case notes # 05

Read the case notes below and complete the writing task which follows.
Hospital: St. Mary's Public Hospital, 32 Fredrick Street, Proudhurst
Patient Details: Ms Bethany Tailor
Next of Kin: Henry Tailor (father, 65) and Barbara Tailor (mother, 58)
Admission date: 01 March 2018 Discharge date: 18 March 2018
Diagnosis: Schizophrenia
Past medical history:
Hypertension secondary to fibromuscular dysplasia
Primary hypothyroidism Levothyroxine 88 mcg daily Social background:
Unemployed, on disability allowance for schizophrenia.
History of polysubstance abuse, mainly cocaine and alcohol. Last used cocaine 28/02/18:
Admission 01/03/2018:
Patient self-admitted: decompensated schizophrenia
Medical background:
Not compliant with medications.
Admitted for auditory command hallucinations telling patient to harm self.
Visual hallucinations — shadow figures with grinning faces.
Delusion — personal connections to various political leaders.
01/03/2018 -
agitated and aggressive, responding to internal stimuli with
thought blocking and latency. Commenced antipsychotic meds
(rispoderone).

10/03/2018:
Patient ceased reporting auditory or visual- hallucinations.
Less disorganised thinking.
No signs of thought blocking or latency.
Able to minimise delusions and focus on activities of daily living.
Nursing management:
Assess for objective signs of psychosis.
Redirect patient from delusions.
Ensure medical compliance.
Help maintain behavioral control, provide therapy if possible.
Assessment:
Good progress, chronic mental illness, can decompensate if not on medications or
abusing substances. Insight good, judgment fair.
Discharge plan:
Discharge on Risperidone 4g nightly by mouth.
Risperidone I milligram available twice daily p.r.n for agitation or psychosis.
back to apartment with follow-up at Proudhurst Mental Health Clinic
Writing Task:
Ms. Bethany Tailor is a 35-year-old patient in the psychiatric ward where you are working as a
doctor
Using the information given in the case notes, write a discharge letter to the patient's primary
care physician, Dr. Giovanni DiCoccio, Proudhurst Family Practice, 231 Brightfield Avenue,
Proudhurst
In your answer:
Expand the relevant case notes into complete sentences
Do not use note form
Use correct letter format
The body of your letter should be approximately 200 words. Use correct letter format.
Case notes # 06

Read the case notes below ana complete the writing task.
Hospital: Fairbanks Hospital, 1001 Noble St, Fairbanks, AK 99701
Name: Mrs Sally Fletcher
Date of Birth: 03/10/1993
Marital status: Married, 5 years Appointment date: 25/03/2018
Diagnosis: Endometriosis
Past medical history:
• Painful periods 3 years
• Wants children, trying I year ++
Social background:
• Accountant, regular western diet.
• Exercises 3 x week local gym
Medical background:
• Frequent acute menstrual pain localised to the lower left quadrant.
• Pain persists despite taking OTC = naproxen.
• Shy discussing sexual history.
• Occasional constipation, associated with pain in lower left quadrant.
• Trans-vaginal ultrasound showing 6cm cyst, likely of endometrial origin.
• Patient recovering post op from laparoscopic
surgery(25/03/2018) — no complications

Post op care: Keep incisions clean and dry.

Mobility post op:
• Showering is permitted 26/03/2018
• Driving is prohibited when on analgesics.
• Driving can be resumed 24-48 hrs after final dose analgesics.
• Sexual activity can be resumed 2 weeks post op.
Nursing management:
• Encourage oral fluids.
• Patient may return to regular diet.
• Ambulation encouraged as per patient tolerance.
Medical progress
• Afebrile. Hct, Hgb, Pits, WBC, BUN, Cr, Na, K, Cl, HC03, Glu all within normal limits.
• Patient sitting comfortably, alert, oriented x 4 (person, place, time, situation).
Assessment:
• Good progress overall.
Discharge plan:
• Patient to be discharged when can eat, ambulate, urinate independently.
• Patient must be discharged to someone who can drive them home.
Writing Task:
You are a first year resident in a surgical ward. Sally Fletcher is a 25-year-old woman who has
recently undergone surgery. You are now discharging her from hospital.

Using the information given to you in the case notes, write a letter of discharge to the patient's
GP, Dr Stevens, Mill Street Surgery, Famham,GUIO IHA

In your answer:
• Expand the relevant case notes into complete sentences
• Do not use note form
• Use correct letter format
The body of your letter should be approximately 200 words. Use correct letter format
Case notes # 07
Read the case below and complete the writing Task.
You are a doctor working in the Stillwater Emergency Department. Today you treated Ms Garcia,
who was referred by her General Practitioner (GP), Dr Bradbury.
Ms Isabel Garcia
DOB: 01.01.1995
Address: 29 Greenfield Road. Stillwater
Medical history: 2007 Fracture R arm
2009 Unexplained weight gain, ?stress
2014 Difficulty sleeping
Certain detergents cause irritation.
Medications: Doxylamine (encouraged not use).
Family History: — Mother- breast cancer. Age 38 years.
Social history: University student.
Reason for referral: Suspected meningitis
23 May 2015
Objective: Painful, stiff joints for I wk.
Sensitivity to light, Increased bruising.
Headache. neck stiffness, photophobia, rash.
On Examination: Afebrile, Bruising L arm, Petechial rash abdomen & legs. Unable to touch chin
to chest when lying.
Tests ordered: Full blood count (FBC), renal function-. liver function test (LFT). C-reactive protein
(CRP). lumbar blood cultures.
Results:
White Blood cell: 14.0X10*8/L
C-reactive proton: 150
Lumbar puncture: White cell 1000 (elevated)
Polymorphonuclear (PMN) (recduced)
Glucose : Reduced
Protein: (elevated)
Subsequent microscopy and culture: Nessiria Meningitidis

Diagnosis: Bacterial Meningitis

Treatment: Ceftiaxone 2g IV bd while awaiting lumbar puncture culture results.

Dexamethasone 10mg IV before first dose of antibiotics, then 10 mg IV every 6hrs for 4 days.
lumbar puncture results: benzylpenciJin I .8g IV every 4hrs for 5 days.
Pt responding well treatment.
Department of Human Services notified.
Discussed with family reassure family immunized.
Plan: Letter GP. recommend.
Contact close family & friends of Pt:
Seek medical attention ASAP — observation for any signs and symptoms of unexplained
illness required.
Chemoprophylaxis for people in recent close contact with Pt.
Writing Task:
write a letter to Dr Bradbury the doctor who referred Ms Garcia. to update her on the patient's
status and follow-up treatment that may be required in the future. Address the letter to Lorna
Bradbury, Stillwater Medical Clinic, 12 main Street, Saltwater.
In your answer:
Expand eve relevant notes into
Do not use note form
Use letter format
The body of the letter should be 180-200 words.
Case notes # 08
Read the case Notes:
You are a venereal disease specialist Working at Department of communicable Diseases,
Australia. Today, you examined Mr. Henry Mathews, referred by his GP, Dr. Kumar.
Patient details:
Name: Henry Mathews
Age: 24 years
Occupation: Local club owner
Marital status: Single
Address: 230 Spencer Street, West Melboume Next of kin: Bethany Mathews (28, sister)
Past medical history:
• ADHD (20th September 2002)
• Mild meningococcal meningitis (12th August 2014)
• Essential hypertension (10th May 2017)
Past surgical history:
• Laparoscopic varicocele repair (25th April 2017)
Family history:
• Father died of alcoholic liver disease 8 years back, was abusive, had multiple extramarital
affairs
• Mother diabetic, caring, volunteer at local community service center
• 3 siblings, patient is youngest.
• Lives with eldest sister who is homemaker
• Twin brother is engineer in China
Personal history:
• Heavy drinker, started after first break-up (July 2014)
• 10-12 cigarettes per day for 15 years
• Occasional one-night stands, new relationship of 14 days
• No previous history of STDs
Medications:
• Hydrochlorothiazide 25 mg OD
• Captopril 12.5 mg PRN (BP >140/90)
• Atorvastatin 10 mg HS

Reason for referral:

• Complicated STD
25/01/2022
Presenting complaints:
• Rash on genitals. extremities. and trunk
• Fever. sore throat, headache. malaise
• Joint pain
Examination findings:
• BP: 130/90 mmHgm Temp. 101F. Pulse: 901min. RR:
181min
• Macubpapular rash all over trunk and extremities including palms and soles (rash
pinkish. symrnetrical. non-itchy)
• Flat. velvety. painless lesions on genitals
• Swollen painful. red knuckles
Test results:
• CBC: Hb 10.5 g/dl. Hematocrit 31.5. Wbc 14.000/ mm3. Neutrophils 86%. Platelets
103.000/ mm3
• Rh Factor. neg
• HIV ELISA: neg
• Hep B & C serology: neg
• Monospot: neg
• RPR: positive
• Dark field microscopy of condylomata: Treponema palidum bacteria visible
• Treponema pallidum particle agglutination (TPPA) test: gx)sitive
Diagnosis: Secondary syphilis
Treatment:
• Tab. Doxycycline 100 mg BID for 14 days
• Tab. Paracetarnol 1000 mg QID for fever. SOS joint pain
• Avoid sexual contact until rash heals completely
• Report any severe. new-onset symptoms immediately
Plan:
• Report local health department
• Update GP for o Proper follow-up o Safe practice counselling (reinforcement) of
Treatment compliance & long-term complications guidance o Inform and assess all possible
contacts maintaining confidentiality
Vaccination (hep B. C)
Writing Task
Using the information in the case notes. write an update letter regarding Mr. Mathews' condition
to his general practitioner. Dr Aneel Kumar working at Melboume City Clinic. 98 BriCk Road.
West Melbourne 3007.
• DO NOT use note form in the letter.
• Expand the case notes where relevant into full sentences.
• Use formal letter format.
The main part of the letter should be approximately 180-200 words long.
Case notes # 09

Read the case notes below and complete the writing task which follows.
Notes:
You are a doctor at Newtown Medical Clinic. Mr Barry Jones is a regular patient Of yours.
Patient: Mr Barry Jones
54 Woods Street Newtown
D.O.B. 01.04.1972 (age 44)
Reason for presenting:
Wants to return to work after back injury — employer supportive
Medical history: 1984 — Appendix removed
Family and social history:
Married — Susan Jones, 3 children
Work — drives forklift in a large warehouse (requires prolonged sitting / occasional heavy-lifting)
Current medications:
Naproxen (non-steroidal anti-inflammatory drug) Carisoprodol (muscle relaxant, blocks pain)
Condition history:
21/03/15 Presentation: Hurt back lifting heavy box off floor at work.

4 days since initial strain. No rest, pain worsening.

X-ray: No disc problems.
Diagnosis: Lower back strain — severe.
Treatment: Exercise: walking daily — gradual increase
time/distance. Referral to physio.
Prescription: naproxen and carisoprodol.
30 days off work and certificate to give to employer. To review in 30 days.

18/04/15 Progress: Back: Still sore.

Moving very stiffly.
Physio: Exercises "very painful" but Pt is compliant. Exercise: Walking up to 10 min per day.
Treatrnent: Extended time Off work — 30 days. TO review in 30 days.

19/05/15 Progress: Back: Recovering well — still in pain. Still moving very stiffly.
Physio: Attending regular appointments.
Exercise: Walking 15-20 mins per day — "very tiring".
Treatment: Increase Naproxen dose.
Extended time off work — 30 days. TO review in 30 days.

20/06/15 Progress: Back: Recovering well — still in pain. Moving stiffly but increased ROM.
Pain increase after 20-30 mins of sitting or lying down. Physio: Still attending appointments.
Exercise: Walking 30 mins per day — "tiring".
Discussions: Pt bored, discouraged, wants to return to work. Restless.
Treatment: Return to work if no lifting & with regular breaks.
Letter to OT requesting assessment of workplace (advise on duties
Pt can perform, etc.).

Writing Task:
Using the information in the case notes, write a letter to Ms Jane Graham, an Occupational
Therapist, detailing Mr Jones' situation and requesting an assessment of his workplace. Address
the letter to Ms Jane Graham, Newtown Occupational Therapy, 10 Johnston St, Newtown.
In your answer:
Expand the relevant notes into complete sentences
Do use note form
Use letter format
The body of the letter should be approximately 180—200 words.
Case notes # 10

Read the case notes below and complete the writing task which follows.
notes:
Today's Date 27/12/17
You are a Psychiatrist at Spirit Hospital Psychiatric Emergency Care Centre (SECC) and Jack Mills is
a patient on the ward.
Patient Details
Name- Jack Mills, DOB 01/09/1996
Marital Status: Single
Admission: 23/11/2017 (Spirit Hospital Psychiatric Emergency Care Centre)
Discharge: 27/12/2017
Diagnoses: Paranoid Schizophrenia/Nicotine Dependence
Family History
Jack's parents separated 4 years ago and divorced 2 years ago
No other children in the family
Psychosocial History
Completed high school; above-average student; often involved in school and
extracurricular activities
He smokes a pack of cigs a day and drinks beer daily. Binge drinking episodes while at
university. He denies any illicit drug use
 He has a keen interest in computers and collected
considerable equipment and software, primarily gifts from his
father
He has been on Disability Support Pension (DSP) since 2016
Medical History: Nil
Symptoms History
May 14, 2016
• Jack was first admitted to SHPW with a 6-month history of confusion, difficulty
concentrating on his studies, and frequent mood swings. He stopped attending university and
was not in contact with his friends.
Diagnosis: Paranoid schizophrenia
• He was hospitalised for 2 weeks & stabilised on Haldol 20 mg and sodium valproate 125
mg, daily.
Plan
Live with his mother in Parramatta (Sydney area)
Referral to psychiatrist arranged along with weekly group psychotherapy in Spirit
Community Mental Health Service,NSW. Discharged 28/5/16
August 2017
Attempted suicide: A possible stressor was that 1 week ago his mother said about ideas
to remarry in the near future
Self-harm through deep cut on both wrists
Hospitalised in ED, surgical tx, under 24hr supervision. Refused to change medication
His attendance in group psychotherapy was irregular.
November 2017
. He has been increasingly isolated for the past 2 weeks, working
on his computer and is very secretive about what he is doing
. He stopped attending his work program, saying that he had "more important work" to do at
home
. His mother believes he stopped taking medications
. Jack refuses to eat or talk with his mother; is nervous because of his mother's plans to remarry)
. He was brought to Spirit Hospital Psychiatric Emergency Care Centre (SECC) by his mother on
23/11/17.
. He has been irritable, suspicious and stated that he has been hearing multiple voices in his
head for the past week.

Hospital progression
• The patient's sodium valproate was increased to 125 bd and then 250 tds
• His need for intramuscular (1M) medication, or other medication was explained. The patient
fiercely objected about injection, saying, "l am a reliable person, I can always take the medicine."
The fact is that he has not been very compliant. After much discussion, the patient has agreed to
take 4 mg of Navane 1M, qid
• Jack received one-to-one, supportive, and insight-oriented psychotherapy on various issues
(importance of compliance,taking meds, and avoiding alcoholic beverages). His participation
through the program was less than adequate as he could not concentrate and focus, but he still
participated in psychotherapy group.
Lab tests
• Serial FBC for had shown WBC ranging from 9.2 to 12. RBC
had ranged from 4.88 to 5.5
• Cholesterol was 5.3 mmoll/L
• T4 was 12.1, the next T4 was 10.1 (normal range 10 - 25 pmol/L), T 3 was 4, 7(normal
range 4.0 — 8.00 pmol/L), TSH has ranged from 1.2 to 1.5 (normal range 0.4-5.0 mlU/L)
• Sodium valproate level was 42 gg/mL (normal range - 50-100 gg/mL)
• Urinalysis - normal
Condition on discharge
• Improving
Ability to manage funds and finances
• Improving
Ability to use good judgment
• Still impaired
Prognosis
• Guarded
Follow-up
. The patient will be living with his mother
. Will be continued on medication (Sodium valproate 250 bd and Navane 1.5 mg 1M q. 4 weeks
(the next dose is due on January 16, 2018)
. LFTs and sodium valproate level to be checked annually
. Cholesterol level to be regularly controlled
. Diet: Low cholesterol
. One-to-one psychotherapy
. Advise to abstain from alcohol & give up smoking
. Vocational rehabilitation and "day programs" to improve self-esteem, quality of life, treatment
compliance, and clinical and social stability
Writing Task:
Using the information in the case notes, write a letter to Dr. Twyford, the Psychiatrist at
Parramatta Spirit Community Mental Health Service, NSW, 2345.
In your answer:
Expand the relevant case notes into complete sentences
Do not use note form
Use correct letter format