Sample OET writing (medicine) case notes and sample letter

A lot of people have been asking me for sample case notes and I’m pleased to say I have now written some! I have done my best to make these notes as realistic as possible and they (like the official samples) are not designed to be easy! This is of course a completely fictional patient and doctor. Please let me know what you think in the comments!

If you’d prefer a pdf you can download for free here:

WRITING SUB-TEST: MEDICINE
TIME ALLOWED: READING TIME: 5 MINUTES
WRITING TIME: 40 MINUTES
Read the case notes and complete the writing task which follows.

Miss Maryam Hassan is a patient in your general practice who is concerned about poor sleep.

PATIENT DETAILS:
Name: Miss Maryam Hassan
DOB: 27.05.89 (Age 29)
Address: 42 West Street, Easthampton

Social background:
Single, no children
Works in fashion design, sometimes has to work long hours
Family history:
Mother died aged 63 due to traffic accident
Father fit and well
Maternal Grandmother diabetes ?Type 2
Nil else significant

Medical history:
Nil significant
Appendicectomy aged 12 (in France)
Allergic to latex
Never smoked, nil alcohol
Goes to gym 3x per week
Current Drugs:
OTC vitamin D
No other prescribed, OTC, or recreational

27/02/19
Discussion:
Concerned re: poor sleeping. Requested sleeping tablet.
Poor sleep hygiene and recent stress at work discussed. Long time at computer in evenings
Occasional headaches and dry eyes after computer use
Slight weight loss (2kg over 2 months, puts down to recent gym membership)
No concerning features of headaches
O/E: Full physical exam: NAD
Weight 62kg, Height 174cm BMI 20.5
BP 125/82
RR 18, HR 85 bpm
Advised sleep hygiene, reduced screen time in evening, reduce caffeine. Advised risks>benefits for sleeping tablet. For review in 2 weeks if not better. Advised OTC artificial tears prn

13/03/19
Worsening sleeping pattern, despite improved sleep hygiene and cessation of caffeine. Has noted occasional palpitations.
Dry eye sensation worsening, although some temporary relief with OTC drops,
O/E: eyes NAD
BP 132/89
RR18, HR 92 bpm (regular)
ECG today: NSR at 88 bpm
Pathology requested: Full profile, TSH. 24 hour ecg,
Review 2 weeks

18/03/19
Pathology report received: TSH 0.3 (low). FBC, U&E, creatinine within normal range. Pt phoned to come in. 24 hour ECG results pending

20/03/19
Pathology report reviewed with Miss Hassan
Symptoms no better.
Advised possible diagnosis of hyperthyroidism and need for specialist referral
Concerned around future fertility, wants to start a family in a few years, advised will need to await investigations

Writing Task:
Using the information in the case notes, write a letter of referral to Dr Dalfo, an endocrinologist at City Hospital, for additional investigations and management.

Address the letter to Dr Pilar Dalfo, Endocrinologist, City Hospital, Easthampton.
In your answer:
● Expand the relevant notes into complete sentences
● Do not use note form
● Use letter format
The body of the letter should be approximately 180–200 words

Sample Answer

Dr Pilar Dalfo
City Hospital
Newtown

20.03.19

Dear Dr Dalfo,
Re: Miss Maryam Hassan DOB: 27.05.89

I am writing to refer this 29 year old patient, with symptoms and preliminary investigations suggestive of hyperthyroidism, for specialist assessment.

Miss Hassan initially presented on 27th February 2019 with poor sleep, dry eyes and occasional benign headaches. Recent weight loss was noted at this appointment (2kg in 2 months) although this coincided with a recent increase in exercise. Her BMI, physical examination and vital signs were all normal. She was advised on sleep hygiene measures and simple eye drops.

Miss Hassan re-attended on 13th March with worsening symptoms and new onset palpitations. Her heart rate was 92 and her ECG was normal. Blood investigations confirmed a TSH of 0.3 (other investigations normal). The results of a 24 hour ECG are pending.

I discussed the potential diagnosis of hyperthyroidism with Miss Hassan today. Of note, she advised she would like to start a family in the future. Miss Hassan is generally well, takes only over the counter vitamin D and is allergic to latex. Her only family history is that of diabetes in her maternal grandmother.

It would be appreciated if you could review Miss Hassan, arrange further investigations as necessary and give advice regarding both further management and implications for fertility. Should you have any further questions please do not hesitate to contact me.

Yours Sincerely
Doctor

Disclaimer:

These case notes and sample letter are intended purely for educational use and do not constitute medical advice. They were written to help candidates in their preparation for the Occupational English Test and are designed to be as close to what may appear in the actual test as possible. However, these are not official materials from the Occupational English Test and therefore their similarity to the actual examination cannot be guaranteed.

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