WRITING CORRECTION

Dr Jack Thomas

Department of Gastroenterology

City Hospital

Main Road

Stillwater

21/02/2015

Dear Dr Thomas,
Re: Mr Patrick Newton, D.O.B: 6/07/1989

I am writing to refer Mr Newton, a 25-year-old accountant, whose features are suggestive of

inflammatory bowel disease, either Crohn’s disease or ulcerative colitis. Your further assessment and
management would be highly appreciated.

Today, Mr Newton presented with the complaints of chronic mild diarrhoea, low grade intermittent
right lower quadrant pain, lethargy, loss of appetite and weight loss of 3 kg for the last 4 months.
However, his symptoms were not alleviated despite dietary modification and use of analgesic.
Additionally, he reported increased anxiety and embarrassment owing to the symptoms.
Examination findings were unremarkable except for generalized tenderness of the abdomen. His
investigation reports revealed increased white cell count, decreased red cell and hemoglobin count.
Furthermore, his fecal occult blood test was positive and both ESR as well as CRP were mildly
elevated. Hence, he was advised on smoking cessation and counselled on IBD.

Mr Newton smokes 10-15 cigarettes per day. His family history is significant for Crohn’s disease
related to his uncle. His medical history is significant for intermittent right and left wrist joint pain for
6 months, due to which he takes Ibuprofen.

I believe Mr Newton has been suffering from inflammatory bowel disease, either Crohn’s disease or
ulcerative colitis. I would be grateful if you could kindly evaluate and treat his condition accordingly.

Should there be any queries, please do not hesitate to contact me.

Yours sincerely,
Doctor
Explanation:

1. Grammatical error was noticed

2. Informal word was noticed. (Furthermore)
3. Layout not maintained. Write personal history after introduction as here smoking, wrist joint
pain and family history of Crohn’s disease are risk factor for IBD

Word count 228

1. Purpose- Satisfactory
2. Content- Relevant info was written
3. Conciseness and clarity- Minimum irrelevant information
Comment was written.
4. Genre and Style- letter was clinical formal and.
Non-Judgmental. Preciseness hampered.
5. Organization and layout- Layout was not maintained
6. Language- Grammatical error was noticed, appropriate
use of comma, Spelling, cohesion was good enough.
1. Follow the sample letter and explanation
part
2. Keep practicing
Advice

Estimated Grade C+ (320)

 A Sample letter of this case note

Dr. Jack Thomas

Department of Gastroenterology
City Hospital
Main Road
Stillwater
21/02/2015
Dear Dr Thomas,
Re: Mr Patrick Newton, D.O.B: 06.07.1989
Thank you for seeing Mr Newton, a 25-year-old accountant, whose clinical features are suggestive
of inflammatory bowel disease either Crohn’s disease or ulcerative colitis. Your further assessment
and diagnosis would be highly appreciated.
Mr Newton smokes 10-15 cigarettes daily. In terms of his medical history, he has intermittent pain in
his both wrist joints for which he takes ibuprofen. Please note, his uncle has a positive history of
Crohn's disease.
Today, Mr Newton presented with the complaints of chronic mild diarrhea and right lower abdominal
pain for four months. In addition, he reported lethargy, decreased appetite and weight loss. However,
dietary modifications failed to improve his symptoms and his condition hampers his social
participation. On examination, generalized abdominal tenderness was noted without any
hepatosplenomegaly. His investigations revealed high levels of WCC, ESR and CRP; whereas, his Hb
and RCC were low along with a positive faecal occult blood test. Hence, he was counseled on IBD
with likely investigations and was advised to quit smoking.
Mr Newton is referred to you for further evaluation and confirmation of his diagnosis.
Should there be any queries, please do not hesitate to contact me.
Yours sincerely,
Doctor