WRITING CORRECTION

Dr Giovanni DiCoccio
Primary Care Physician
Proudhurst Family Practice
231 Brightfield Avenue
Proudhurst

18/03/2018

Dear Dr DiCoccio,
Re: Ms Bethany Taylor

I am writing in regards to Ms Taylor, a 35-year-old lady who is being discharged today after having
successfully recovered from an episode of decompensated schizophrenia. Your further follow-up care
would be highly appreciated.

Ms Taylor, a known schizophrenic, was admitted to the psychiatric ward of St. Mary’s Hospital on
01/03/2018 with the complaints of auditory and visual hallucination, as well as delusion. Additionally,
she was found to be non-compliant to her medications. Her mental state examination revealed that she
was agitated, aggressive, responding to internal stimuli along with thought blocking and latency.
Hence, she was commenced on risperidone. As you are already aware of her history of cocaine abuse,
it should be mentioned that her last instance of cocaine use was on 28/02/2018.

During hospitalisation, Ms Taylor gradually displayed signs of improvement. Upon assessment on

10/03/2018, hallucination was absent, delusion was minimal and she could focus on her daily living.
MSE revealed less organised thinking and absence of thought blocking or latency. Please note, she
received nursing assistance regarding compliance to medication, control of delusion and behaviour, as
well as necessary therapies.

Upon assessment prior to discharge, she exhibited good progress towards recovery. MSE showed
good insight and fair judgement. She was prescribed risperidone 4g once daily at night, and 1 mg
twice daily in case of agitation or psychosis as required. Given that she is schizophrenic which is a
chronic mental condition, non-compliance or substance abuse could lead to further episodes of
decompensation.

I would be grateful if you could monitor her condition.

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

Yours sincerely,
Doctor
Explanation:

1. Grammatical errors were noticed.

2. Unnecessary sentences noted
3. Word count exceeded

Word count 260

1. Purpose- Satisfactory
2. Content- word count exceeded
3. Conciseness and clarity- Minimum Irrelevant
Comment information was written.
4. Genre and Style- letter was clinical formal and non-
Judgmental. Preciseness hampered.
5. Organization and layout- Layout was 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 B (350)

 A Sample letter of this case note

Dr Giovanni DiCoccio
Proudhurst Family Practice
231 Brightfield Avenue
Proudhurst

18-03-2018

Dear Dr DiCoccio,
Re: Ms Bethany Tailor

I am writing in regards to Ms Tailor, a 35-year-old lady, who is being discharged today after being
treated for decompensated schizophrenia. Your further follow-up care would highly appreciated.

On 01-03-2018, Ms Tailor admitted herself with the symptoms of audio-visual hallucinations and
delusion. In addition, she showed agitation and aggression along with response to internal stimuli with
thought blockage and latency. Additionally, she was non complaint with medications. Therefore, she
was commenced on risperidone.
During hospitalization, Ms Tailor's condition had gradually improved with being able to focus on her
daily activity and cessation of audio-visual hallucinations as well as delusions. During her nursing
management, she had maintained behavioral control and exhibited compliance to her medications.

Today, Ms Tailor is being discharged with medications including risperidone 4g at night and 1mg
twice daily in case of agitation or psychosis along with advice to follow-up at Proudhurst Mental
Health Clinic. However, medications for hypertension and hypothyroidism should be continued.

I would be grateful if you could monitor Ms Tailor and provide special attention to avoid relapse of
her condition. Your expert assessment and management will definitely benefit her.

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

Yours sincerely,
Doctor
Case Note