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    005 Writing Medicine Miss Cathy Jones Referral Letter To Gynaecology

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    Joan Manabat Bugna
    Miss Cathy Jones, a 25-year-old receptionist, presented with lower abdominal pain. On her first visit, she was mildly tender but otherwise normal. On her second visit, her pain had worsened and she was very tender in the right iliac fossa with guarding. A positive pregnancy test and cervical excitation indicated a suspected ectopic pregnancy, so the GP referred her to the gynaecology registrar for urgent assessment and asked to be informed of the outcome.

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    005 Writing Medicine Miss Cathy Jones Referral Letter To Gynaecology

    Uploaded by

    Joan Manabat Bugna
    328 views3 pages
    Miss Cathy Jones, a 25-year-old receptionist, presented with lower abdominal pain. On her first visit, she was mildly tender but otherwise normal. On her second visit, her pain had worsened and she was very tender in the right iliac fossa with guarding. A positive pregnancy test and cervical excitation indicated a suspected ectopic pregnancy, so the GP referred her to the gynaecology registrar for urgent assessment and asked to be informed of the outcome.

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    005 Writing Medicine Miss Cathy Jones Referral Letter to Gynaecology

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    Miss Cathy Jones, a 25-year-old receptionist, presented with lower abdominal pain. On her first visit, she was mildly tender but otherwise normal. On her second visit, her pain had worsened and she was very tender in the right iliac fossa with guarding. A positive pregnancy test and cervical excitation indicated a suspected ectopic pregnancy, so the GP referred her to the gynaecology registrar for urgent assessment and asked to be informed of the outcome.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    328 views3 pages

    005 Writing Medicine Miss Cathy Jones Referral Letter To Gynaecology

    Uploaded by

    Joan Manabat Bugna
    Miss Cathy Jones, a 25-year-old receptionist, presented with lower abdominal pain. On her first visit, she was mildly tender but otherwise normal. On her second visit, her pain had worsened and she was very tender in the right iliac fossa with guarding. A positive pregnancy test and cervical excitation indicated a suspected ectopic pregnancy, so the GP referred her to the gynaecology registrar for urgent assessment and asked to be informed of the outcome.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3

    Writing Task I Doctors

    Read the cases notes below and complete the writing task tl-rat follows

    Time allowed: 10 minutes

    Today's Date

    16.02.09

    Patient History

    Miss Cathy Jones - 25 year old single woman


    Occupation - receptionist
    Family history of deep vein thrombosis
    On progesterone-only pill (POP) for contraception
    No previous pregnancies

    15.02.09
    Subjective

    Presents to GP surgery at 7 pm, after work


    Complains of lower abdominal pain since the evening before, worse in right iliac fossa
    Unsure of last menstmal period, has had irregular bleeding since starting
    POP 2 months ago, New parlner for past 2 months
    No bladder or bowel symptoms

    Objective

    Mild right iliac fossa tenderness, no rebound / guarding

    Apyrexial, pulse 88, BP 110/70


    Vaginal examination - quite tender in right fomix. No masses

    Assessment

    Non-specific abdo pain

    Plan: Asks her to return in morning for blood test anil reassessment

    16.02.09

    Subjective
    Pain has worsened ovemight. Now severe constant pain.
    Some slight vaginal bleeding ovemight also.
    Felt faint while waiting in reception.
    On questioning, has left shoulder-tip pain also.

    Objective

    Very tender in the right iliac fossa, with guarding and rebound tendemess
    Apyrexial, Pulse 96, BP 110/70
    On vaginal examination, has cervical excitation and markedly tcnder rn the right fornix.
    Pregnancy test rcsult positivc
    Urine dipstick clear

    Assessment

    Suspected ectopic pregnancy

    Plan: You ring the on duty Gynaecology Registrar and ask for urgent assessment. and are
    instructed to send her to the A&E Department u,ith a refcrral letter.

    Writing Task

    You are the GP, Dr Sally Brorvn. Write Refen'al letter to the Gynaecology Registrar at
    the Mater Hospital, South Brisbane. Ask to be kept informed of the outcome.

    ln your answer:

    . Expand the retevant case notes into comptete sentences


    . Do not use note form
    . The body of the letter shoutd not be more than 200 words
    . Use correct [etter format
    Task 1 Model Letter: Cathv.Iones

    Gynaecology Registrar
    A&E Department
    Mater Hospital
    South Brisbane

    Dear Doctor,

    Re: Cathy Jones DOB 1.12.83

    Thank you for seeing this 25 year old woman who I suspect has atr ectoprc pregnancy.

    This is her first pregnancy. She presented to the surgery yesterday evening with vaguc
    lower abdominal pain. She starled the progesterone-only pi1l for contraccption two
    months ago, when she starled a new relationship, and has l-rad some irregular blceding
    since then. Therefore she is unsure of her exact last menstrual period. Ycsterday. she u,as
    mildly tender only and her obsen,ations were normal.

    However, on revicw this morning her pain had worsened overnight, she is verv tender in
    the right iliac fossa, with rebound and guarding, and on vaginal examination tl-rerc is
    cervical excitation, and marked tendemess in the right fomix. Her pregnancy test is
    positive .

    I am concemed that she may have an ectopic pregnancy, and would appreciate your
    urgent assessment.

    Please keep me informed of the outcomc.

    Yours sincerely,

    Dr Saiiy Brown (GP)

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