Ticket Id: 200533
19 March 2022
Dr George Lopez
Pediatrician
City Medical Center
Chebucto Rd
Kentville
Dear Dr Lopez,
Re: Lauren Goldsmith, DOB: 18/11/2021
I am writing to refer Lauren Goldsmith, a 4-month-old infant with recurrent UTIs, for future UTIs and
renal failure prevention.
Lauren was delivered normally at 37 weeks gestation, she weighed 2.9 kg, and she had no antenatal or
postnatal complications.
On 10/03/2022, Lauren's mother brought her complaining of a fever that was not responding to
ibuprofen for 2 days. She had a fever of 104.7°F, elevated WBC count as well as agitation. She was
refusing to eat. Therefore, she was admitted for further investigation.
Two days later, Lauren was started on Zosyn and ibuprofen. However, she continued to have a high fever
and elevated WBC count. A lumbar puncture was performed, which was negative, along with obtaining
blood and urine cultures. A couple of days later, her urine culture came back positive for E. coli infection,
for which Bactrim was commenced and Zosyn was discontinued.
On 18/03/2022, Lauren's fever and WBC range normalized. She was acting normal. Consequently, Bactrim
and ibuprofen were discontinued. However, given her positive history of UTI at 2 months, her mother was
concerned for congenital kidney defect, for which an US was ordered. Commented [ESLDOC1]: about a
Commented [ESLDOC2]: a
Today, Lauren's abdominal US showed a defect causing VUR. Kindly note, she needs surgery referral to
prevent future UTIs and renal failure.
If you require any further information, please do not hesitate to contact me.
Yours sincerely,
Doctor
Report
Word Length 203
Comments The purpose is apparent and developed sufficiently in the
introduction and conclusion. The case notes' content is adequately
represented. The length of the letter is appropriate. The writing
style is formal and polite. Organization and paragraphing are logical
and straightforward. Some slips in language and grammar do not
interfere too much with the overall understanding of the letter.
Estimated Grade A
Estimated Score 450/500
Advice 1. Revise grammar (Articles/Prepositions).
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