Writing

Dr. Issacson or Dr Issacson

Cardiologist
45 Inkerman Street
Caulfield 3162

19th January 2007 or 06\09\2013 or 19 march 2018

Dear: Dr. Issacson, or Dear Dr Issacson, or

Re: Mr. Jing Zu, Age: 72 years or ,DOB: 06\09\2013 or Aged 26

a) Introduction: (contain the main medical issue and the purpose of writing)
(mainly 2 sentences) (about 25 words)
( tense : present : mainly present continuous
Or present perfect continuous)

1) First sentence:
* Thank you for seeing Mr (last name), an 80-year-old patient,
* I am writing to refer Mr (last name), an 80-year-old patient,
* I am writing to refer Mr (last name) into your care
* Thank you for seeing this 8-year-old female child.
May add "As arranged with your receptionist", thank ……
If proviginal diagnosis: add
* whose features are suggestive of (………).
* who is presenting with (symptoms) suggestive of (………).
* who is presenting with (symptoms) consistent with (………) and
require …( full neurological assessment and further investigations).
* who has been suffering from ……… and require …..(e.g some personal
assistance in her home)

* who has been demonstrating symptoms suggestive of…….

If definit diagnosis: (biobsy) add

* who has been recently diagnosed with (adenocarcinoma)
2) second sentence:
* Your further management would be highly appreciated.
* Your surgical assessment would be highly appreciated.
* Your neurological assessment would be highly appreciated.
* I would be grateful if you could manage his condition as you think
appropriate.
*

Discharging letter:
First sentence:
* Mr (last name) was admitted to ( hospital) on (date) for the purpose
of …..

* Mr (last name) admitted himself to ( hospital) on (date) . he has

been suffering from ……..

* Thank you for seeing Mr (last name), an 80-year-old patient, who is

being discharged today after …… into your care

second sentence
She is now ready for discharge and follow up at your clinic.
,, ,, ,, ,, ,, ,, ,, ,, ,, into the care of her husband.
,, ,, ,, ,, ,, ,, ,, ,, ,, to your nursery facility.
Your further follow up would be highly appreciated.

I am writing this letter to update you regarding the condition of Ms.

b) Expository paragraph:
(Social, family and medical Hx) (About 45 words)
(tense : present : mainly present simple
Or present perfect continuous)

NB: if there is many visits, we can include on or two minor visits in the expository.

Soial :
* Mr (last), who is widow\married and has four children, lives alone and
this is why his case requires maximum attention.
* she is the first child of a family of 5, including his parents and siblings
* Mrs. Welshman, who has been my patient for the past eight years,
lives alone

Medical : Addition CD,……..

He is a heavy smoker. However, he is not a drinker.
Though she is a non-smoker, she is a social drinker.
His medical history is unremarkable apart from……which has been
managed accordingly
He does not have a remarkable past medial history. Nevertheless, he
takes sleeping pills occasionally.
His medical records reveal that he has a long history of …. For which he
has been taking ……

Ms Forrest was first diagnosed with asthma at age four and has been
hospitalized on two occasions with severe exacerbations
He has a significant medial history of DM, HTN and hyperlipidemia.

he is allergic to…..
he has an allergy to….
 he has no known history of allergies.

Family :
* Addition CD, He has a positive family history of ……..
* Regarding her family history, her mother died (of) due to…. , while
her father died of….
, he has no family history of …… or ……

* he has a family history of Crohn's disease in his uncle

* In terms of her family medical records,

Her mother died at the age of 50 of bowel cancer

Her mother died at 50 years of age of bowel cancer
Her mother died when she was 50 years old of bowel cancer.

* Apart from a positive family history of ……. In her mother, she has been
otherwise well.

Visits : use past simple tense, past perfect

First visit: we can summarize minor visits ( complaint + TTT)

* On (date), Mr X presented with … which had been present for 2 weeks

* On (date), during his regular follow up visit, Mr X presented with … which

had been present for 2 weeks

. * On (date, Mr X presented complaining of ….. Therefore, he was

commenced on …….(ocp).
* On (date, Mr X visited my clinic complaining of ….. Therefore, he
was advised to ……..
* Initially, Mr X visited my clinic on (date) complaining of
* On (date), Mr X attended my clinic because he had been suffering *
from …. Which was treated symptomatically with …..
* Mr Xs first visit was on (date) because …..
 * The patient, accompanied by her parents, initially presented on (date)
with…
‫لو فيه زيارات مش مهمة‬
Following this visit, she came on different occasions for other medical
issues.

Second visit:
if minor and related we can say

* Her condition continued to deteriorate in the next 4 days as ….( his

temp could not be controlled with antipyretics). Thus,….

* His condition showed no signs of improvement as ……

* His condition had not improved; therefore, some investigations were
ordered.

* Despite advice from a dietician and attendance at various weight-loss

programs, there has been no improvement.
The same previous signs of …. Were deteted.

if minor and not related we can say

* Seven months later, he reported having…….. over the past several
weeks. At that time her BMI was … thus, ……
* Seven months later, he had suffered from…….. over the last 4 weeks.
* Seven months later, on her second visit, she stated that she was feeling
….. especially after
family
If u want to add examination, invest. or treatment as below

c) Major visit: ( complaint + O\E + investigations + Plan of TTT)

= Complaint:
 * Seven months later, he reported having…….. for the past several weeks.

* On (date) , MR X attended the clinic with a two-day history of ……

* however, she denied having fever,……,…..or……
* on his subsequent visits,…..

= Examination:
* On examination\assessment, he was ill looking despite the unremarkable
abd. EX.
* Upon examination\assessment, BP was ….. and temp was …..
* Examination showed …..(
* Her Examination revealed that she was severely febrile with a
temperature of
40.2 and a pulse rate of 110 per minute.
* Her examination was unremarkable except for signs of ….and ….
* Cardiovascular examinations showed…….

= Investigations: Result CD, invest. + were requested

* As a result, CBC, FOBT and colonoscopy were ordered to rule out any
suspicion of bowel cancer or inflammatory bowel diseases.

* Therefore, an MRI and other relevant investigations were ordered.

* On her x-ray and ct, …….. together with….. were detected.
* Otherwise, the rest of her investigations were normal
* Investigations showed a decreased level of…... and elevated levels of…..

= TTT: Result CD,…..

* Thus, he was advised to stop smoking, do exercises and visit a physiotherapist.
* he was encouraged to ……
* he was prescribed …… and ….. which did not help.
* he was commenced on
* he was managed with ……
* he was counseled about his smoking habits
* ……,…….. and …. Were given.
* I have reinforced with Ms Forrest the importance of taking……

c) Todays visit:
* On today's visit, the investigations showed ……(derease HB level, positive FOBT)
 * Today, Mr X attended to check his results which were disappointing. To
illustrate,
* On today's visit, the patient requested to be referred to …… as….. .
Investigations showed high levels of…

* On today's visit, the patient, accompanied by her daughter, visited my

clinic concerned about her memory issues as she was forgetting dinner
engagements and social events.
* On review today,
* On review today, the patient requested to be referred to an
endocrinologist as she has been having difficulty in conceiving after OCP
cessation since January

d) conclusion:
* In view of the above, I am referring her for urgent assessment.

* In light of the above, my provisional diagnosis is…… thus, Mr X is being

referred into your care.

* In light of the above, I would be grateful for your thoughts on what is the
definite diagnosis might be and how could be managed accordingly.

* In light of the above, your expert views on the possibility of surgery after
an MRI scan would be highly appreiated.

* In light of the above, I would be grateful if you could arrange a

consultation to assess his (neurological) condition and determine the
suitability of ….(MRI). (If definite diagnosis and mentioned in introduction)

* In view of the above, I believe she needs urgent admission..

* In light of the above, I am referring Mrs. Welshman for a full memory

assessment and diagnosis

*
I would also appreciate your opinion on whether or not she should continue
as prescribed with her current medications.

* Taking into account of her history, I believe that this could be a case of
unstable angina. Therefore, I am referring her for ….. .

Add:
* Should there be any queries, kindly do not hesitate to contact me.
* If you have any question, please feel free to contact me.
* please feel free to contact me, if you require any further information
regarding this patient.

Cohesive devices
NB: must followed by simple sentence
1) Result:
- As a result, - Consequently, - Thus,
- Therefore, - Hence, - For this
reason,
- based \ In view \ In light of the above, - As a consequence
- regarding + noun - based on + noun
2) Contrasting:
- Nevertheless, - Nonetheless, - However,
- Conversely, - Otherwise, - On the other
hand

3) Addition:
- In addition, - Additionally, - Furthermore,
- Moreover, - Plus, - Apart
from that,

4) Emphasis:
- Please note, - please note that - kindly note that
- It's important to know that - It's worth mentioning that
- May remind you that - it should be noted that

5) Clarification:
- To illustrate, - To augment, - To explain,

His investigations were disappointing. To illustrate, his FOBT

was positive.

6) sympathy:
- Fortunately, - Unfortunately, - Regrettably,

7) Timing:
- On 09\08\2005, - At that time,
- On review today, - Since that time,
- On review after 3 weeks, - Over the past 3 weeks,
- Two weeks later, - Today,
- Two weeks ago, - Yesterday,
8) Location:
- During Hospitalization, - On examination,
Connectors

and = in addition to = together with = along with = combined with =

Followed by + item