Scenario date: 18 June 2018
You are a practitioner examining a 45-year-old female patient, Ms Anne Hall.
Using the information in the case notes, write a referral to Dr Jason Roberts, gastroenterologist, at Newtown Hospital, 111 High Street, Newtown.
In your answer:
The body of the letter should be approximately 180–200 words words.
| Name: | Anne Hall (Ms) |
| DOB: | 19 Sep 1972 |
| Height: 163cm Weight: 75kg BMI: 28.2 (overweight 18/6/18) | |
| Social History: | Teacher (Secondary – History, English); Divorced, 2 children at home (born 2002, 2004); Non-smoker (since children born); Social drinker – mainly spirits |
| Substance Intake: | Nil |
| Allergies: | Codeine; dust mites; sulphur dioxide |
| Family History: |
|
Plan:
Grade B Model Answer
Read this letter carefully. The annotations below explain the techniques used for each OET criterion. After studying this example, try a practice case yourself.
18 June 2018 Dr Jason Roberts Gastroenterologist Newtown Hospital 111 High Street, Newtown Dear Dr Roberts, Re: Ms Anne Hall, DOB: 19 September 1972 I am writing to refer Ms Anne Hall, a 45-year-old female patient, for further investigation and management of her dysphagia. Ms Hall presented today with a two-week history of difficulty swallowing solids, which developed following a viral upper respiratory tract infection. She self-medicated with an over-the-counter Chinese herbal product of unknown composition, which has since been ceased. There is no relapse or remittent course, no sensation of a lump, and no obvious anxiety. She also reports concomitant epigastric pain radiating to her back at the T12 level, a recent weight loss of one to two kilograms, and an increase in coffee consumption. She takes aspirin occasionally (two to three times per month) and no other NSAIDs. Of note, her father had a peptic ulcer. She is allergic to codeine, dust mites, and sulphur dioxide. A provisional diagnosis of gastro-oesophageal reflux with possible stricture has been made. Pantoprazole 40mg daily has been commenced, and she has been advised to reduce her coffee and alcohol intake. I would be grateful if you could assess Ms Hall and arrange endoscopy if clinically indicated. Please do not hesitate to contact me should you require any further information. Yours sincerely,
“I am writing to refer Ms Anne Hall, a 45-year-old female patient, for further investigation and management of her dysphagia.”
Immediately apparent: states the letter type (referral), names the patient with age, and gives the specific clinical reason (dysphagia). Not a generic opener.
“Ms Hall presented today with a two-week history of difficulty swallowing solids, which developed following a viral upper respiratory tract infection.”
Case notes converted to a full sentence. 'Dysphagia (solids)' becomes 'difficulty swallowing solids' — accurate, formal, no note form. Patient referred to by name (not 'the patient').
“She self-medicated with an over-the-counter Chinese herbal product of unknown composition, which has since been ceased.”
Passive voice used correctly ('has been ceased') — avoids 'I told her to stop it'. Formal and professional tone.
“There is no relapse or remittent course, no sensation of a lump, and no obvious anxiety.”
Relevant negative findings are included — a gastroenterologist needs to know these to assess risk. Not omitted just because they are negative.
“Of note, her father had a peptic ulcer.”
Family history of peptic ulcer IS relevant to a gastroenterologist. Childhood asthma, tonsillectomy, and depression (from the case notes) are correctly omitted — outside the reader's scope.
“A provisional diagnosis of gastro-oesophageal reflux with possible stricture has been made. Pantoprazole 40mg daily has been commenced, and she has been advised to reduce her coffee and alcohol intake.”
Passive voice throughout ('has been made', 'has been commenced', 'has been advised'). Management already initiated is clearly summarised for the gastroenterologist.
“I would be grateful if you could assess Ms Hall and arrange endoscopy if clinically indicated. Please do not hesitate to contact me should you require any further information.”
Expands the purpose at the end: specifies exactly what is being requested (assessment + endoscopy if indicated). Closes with a professional offer of further information — never ends abruptly at 'Yours sincerely'.
“Yours sincerely,”
'Yours sincerely' is correct because the recipient is named (Dear Dr Roberts). If the recipient were unnamed (Dear Doctor), it would be 'Yours faithfully'.
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