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Uncle Louis’ Guide to Case Write-Ups

Most of this advice, though simple and logical is based largely on the comments I have
found myself giving to students over the past few years about their assignment write-ups.
Before one starts the assignment, one ought to consider some basics rules of engagement.
Being that we are a Commonwealth Country, and Queen Elizabeth II of England, is also
Queen of Australia, could we please show our delightful monarch the basic respect of
NOT butchering her language. On becoming a republic, and doing away with an official
language altogether, I will be prepared to soften up on such observances, and would
under such circumstances, even accept US English, as valid syntax. However, until such
times English will be the official language in which I would expect you to present your
assignments.
Here are some simple examples of common mistakes:-
The word ‘Nauseous’ in US English describes the feelings or sensations one experiences
as a prelude to a vomit. However, in the Queen’s English, the word ‘Nauseous’ is
synonymous with the word ‘Nauseating’. The practical upshot of this, is that should you
state that ‘The patient is nauseous’, I will assume you are slandering the patient, by
making the comment that this poor suffering soul makes you feel like ‘throwing-up’.
Because our medical system is still essentially British, when we remove somebody’s
appendix, this occurs in an operation referred to as an ‘Appendicectomy’, which is in
sharp contrast to the US English word ‘Appendectomy’. I will expect you to use English
words, and abbreviations rather than US English equivalents. British folks such as
Australians, have an organ called an Oesophagus, and when we suffer from acid reflux
into this organ, we are said to suffer from Gastro-Oesphageal Reflux Disease, or GORD.
Unlike our much beloved allies in the USA who have a similar organ called an
Esophagus, and when they suffer from acid reflux into this organ are said to have GERD.
For the smarty pants students among you, should your patient be a citizen of the USA,
whilst they are unwell in Her Majesty’s realm, they will have symptoms, organs, illnesses
and concerns in Her Majesty’s English.
The Progress Notes

As you will no doubt be abundantly aware, the long case portion of your assignment
should be written on Q-Health issue Progress Notes, or a manner of lined page which at
least looks largely like genuine Progress Notes.
In the top right hand corner of the page will be a ‘patient details box’, you must have at
least three vectors of identification in this box, e.g. Name (though in the case of the
assignment the initials or the pseudonym which is being used for the patient), Date of
Birth, Gender. In real life each page of the progress notes should have these details filled
in (or a sticky label with these details), which is to protect against the notes becoming lost, or worse still, misplaced into another patients notes. This could have the effect of recommending treatment which would be detrimental to the patient into whose file the sheet was placed incorrectly. I will expect that each sheet of paper has this data satisfactorily completed. The ruled margins around the page are not ‘guidelines’ as to where one might desire to end the line of writing. The margins are just that, ‘Margins’, do not write over the margin, you are expected to stay within them. Start your documentation with a description of your designation. For example, the entries I write in a set of patient notes would tend to look a little like:- 02-01-08 Peachey/Anaesthetics/1330hrs If you have an alternative manner of making such a note, which clearly tells the reader
who it is that is writing this set of notes please feel free to use it.
You must use both sides of the progress notes when writing your assignment. In the real
world, the admission notes constitute a legal document, and leaving whole pages blank in
the notes, only gives the opportunity for somebody to alter the notes after the fact, which
would in a legal sense, throw into doubt the veracity of all of your work
The Approach to the Case

Students are often concerned about how to present the case, if they have seen a patient
the day after the appendicectomy, and as such after a final diagnosis has already been
definitively settled should they write the case pretending to be the ED resident, or the
ward resident the following day?
The question they are actually considering, is should they write the case as a ‘Diagnostic
Case’, or as a ‘Management Case’. If the case is written as though the operation is yet to
take place, the main emphasis will be on confirming a diagnosis, and excluding the
differentials. However, if the case is written as the ward resident seeing the patient the
following day, the issue is no longer the diagnosis, but rather what needs to happen now
for the patient’s recovery. Such issues as how soon can the patient eat, how soon can they
mobilise, how do we manage their pain, how quickly can they resume their normal lives.
Given that this is your first clinical year, and that the emphasis at this point is your
diagnostic processes, rather than detailed management, which you will hone in 5th and 6th
year, I would recommend you write the case as a ‘Diagnostic Case’. Evidently, in the
patient after the appendicectomy, the examination of the abdomen will not be consistent
with the presurgical findings, in which case you simple state how long after the operation
you examined the patient, and we will agree to suspend disbelief for this aspect of your
case write up. I am more concerned that you perform a full examination, and get the
practice, rather than that the physical examination occurs after the fact.
The History – Presenting Complaint

The History begins with the Presenting Complaint. This should describe (preferably in
the patient’s own words) the symptom or set of symptoms which provided the patient
with the impetus to seek help on this particular day. Occasionally, one might see a patient
who did not seek attention due to a specific set of symptoms, but rather a genuine ‘check-
up’, during which an abnormality was discovered, which then leads to further
investigation. Nevertheless, in most cases, you will describe the set of symptoms which
led to the patient seeking help. If you do use the patients own words, these should be
placed between a set of inverted commas, also know as ‘Quotation Marks’. If you use a
sentence which has no sense of English grammar, but is in quotation marks, I will assume
that the patient was in such distress, as to simply be unable to avail themselves of Her
Majesty’s rules of grammar. If this grammarless phrase finds its way to the page without
quotation marks, I will take this as a personal snub to Her Majesty, and this will of course
be reflected not only in your marks, but the comments I pass to the tutors who are to take
you in future terms.
The History – History of Presenting Complaint

This is where you will need to flesh out the details of the Presenting Complaint, as well
as any other associated symptoms, other important risk factors which might relate to their
current presentation, and start to build the picture of this person’s pre-morbid state (was
this person fit and well prior to this presentation, do they already suffer from multisystem
disease, or are they on the sliding scale between).
Pain is probably the most common reason people present for acute care, closely followed
by a change in body fluids which might be frequency, colour, consistency, etc. I suggest
that you attempt to build a word graph, so that the reader can get an appreciation as to
when the presenting symptom first began, how long did it take from initial symptoms to
its peak, is it now at a steady state, is its intensity best described as a sinusoidal wave
form. If it is pain, what is its location, has it shifted, is there any radiation, what gives the
patient relief, what makes the sensation worse.
Frequently, during this part of the write-up students will start to make comments as to
what the patient ‘admits’ or ‘denies’. I will ask you to avoid such judgment laden
language, as you are to be your patient’s advocate, not the opposing legal counsel
undertaking a cross examination. Using value laden language about what the patient
‘admits’ or ‘denies’, does not make you sound objective, simply adversarial. If you are
unable to cope without using some form of language to denote your objectivity, you
could consider the phrase ‘The patient stated….’, which does not say that you accept or
reject the veracity of their recall, simply that it is the information which the patient
offered.
At about this stage you will start to feel some discomfort as to which bits of the patient
history belongs in which section. If the patient’s initial presentation is epigastric
discomfort, for which you know cardiac ischaemia needs to be considered as part of the
differential, will this person’s smoking history go in the History of Presenting Complaint,
or in the Social History. To which the answer is, ‘Welcome to Clinical Medicine, and the
Tolerance of Ambiguity’. If this uncertainty is too distressing for you, then you really
should be discussing this with your professional mentor, and if you don’t have at least
one such mentor, it is time to go look for one, preferably someone who will be willing to
take your phone calls for the next ten years or so.
The History – Past Medical/Surgical History

This may be as a single section or as two separate sections, depending largely on its
complexity. I would recommend that you use a chronological order, as best as possible
giving the year, if not the specific month or day, when a condition was first diagnosed, or
when surgery took place. With Surgical Histories, it is worth noting where the operation
took place, as from time to time it will appear that there was some complication of the
surgery or anaesthetic, for which some documentation would be useful.
As previously stated, I will expect you to use the English word for the operation, if you
are unsure look up a medical dictionary, most will tell you the alternative English and US
English versions of the operation. It might also be useful at this point to take a moment to
appreciate the etymology of the word, and gain further experience in Latin or Greek
roots, which will be valuable in helping you understand other areas of medicine. Being as
most of us are ‘nerds’, as it is a known, albeit unstated, entry criteria into medical school,
it is about now in your career that you should learn not to feel ashamed of your
excitement in gaining new insight into the etymology of medical words.
The History – Medications

The medications must be written using their generic name, feel free to write the
proprietary name in brackets after the generic name, and you must also state dose and
frequency of dose. For the dose you might represent this as the dose in each tablet or
capsule then how many tablets or capsules, however often:-
Medications
Or just the total dose taken on each occasion. Medications At around this time it would be useful for you to acquaint yourself with the MIMS booklet, which has much of this detail. Later when you make suggestions as to how you might manage the patient’s acute presentation, should you choose to mention any medications, and be so bold as to suggest doses, I would expect that it will reflect real life
practice, and having some familiarity with reading a MIMS would help substantively in
this task. Be careful of using American pharmacology textbooks, as given the American
obsession with putting patents and trademarks on anything that isn’t already nailed down,
they do use different generic names from the British world. Instead of Adrenaline, they
have Epinephrine ‘Epi’, this is because Adrenalin is copyrighted, and Adrenaline is too
close in spelling to be used in American texts. This is also true for some other drugs, so
be careful of a seduction into the Dark Side. When in Her Majesty’s realm, do as Her
Majesty would.
The History – Allergies/Adverse Reactions

Whenever possible if the patient has had a history of an adverse reaction, it is good to
collect whatever data is available about the type of reaction, when it occurred and how
we connect that to the drug in question.
There are any number of people who report a non-urticarial, non-itchy rash as an allergy
to antibiotic therapy, when in fact the patient was suffering from a viral illness, and did
not actually need the antibiotics anyway, had a viral exanthem which would have
expressed itself with or without the antibiotics. Although I don’t expect a 4th year medical
student to make the call whether a description of a rash 10 years ago was truly Urticarial
or actually a viral exanthem, I would like you to approach this data with a critical
scientific method, rather than as a simple reporter of received information.
From time to time in your professional life, you will come across patients who are
reported to be allergic to all available antibiotics for their current life threatening sepsis.
At this time you will appreciate the need to differentiate between true allergies, and
medical coincidence, in finding an available treatment for your patient.
The History – Immunisations

If you choose to simply write up-to-date, this is by all means okay. However, do expect
to get a phone call whilst I am marking the paper, during which I will ask you ‘So what is
the correct childhood immunisation schedule that was in place when Mr Smith was born
in 1964, and what other immunisations should he have had as an adult’. If it so happened
that you were subsequently unable to answer such a question, I would know that you
simply faked the knowledge. Instead I suggest that you report what you are able to find
out. The patient might ‘state’ that to the best of their knowledge they received all of their
childhood immunisations, and has subsequently had tetanus, fluvax and Hep B shots as
an adult. From time to time you will also come across a patient whose parents were
conscientious objectors to childhood immunisations and may not have had any. So please
report what you know, not what makes it look like you asked when you did not.
The History – Family Medical History

This can be written long hand, or a simple family tree illustration might be a more
efficient way to display the information.
Remember the point of this write-up is so that other members of the team can get an
accurate feel for the patient’s circumstances, particularly your consultant, who is likely to
get much less sleep than you do. So anything that you can do which makes the conveying
of information more efficient is a sensible option. If the patient was adopted, and has
little or no family history available, say so. Alternatively, if the patient is estranged from
his or her family, and is not aware of the detail, simply state that in this section.
The History – Social History

Seen by some of the luddites among us as the touchy feely part of the history, this section
is likely to contain some of the key information which will shape our specific
management plan for this patient, particularly what level of self care the patient will need
to achieve before we should be ready to discharge them from our care.
As well as salient details of this patient’s social supports and social obligations, it is
worthwhile to consider the architecture of the house as it may influence your ability to
get the patient home, or you may need to organise a home assessment prior to discharging
your patient. An important indicator of good hospital care, is how often the patients will
return before the illness has fully resolved, understanding the home circumstances into
which you are discharging your patient will give you a much better chance of making
sure the patient is ready before discharge.
If you have not found the need to make specific note of the patient’s social drug habits up
until this time, now is a good time to do so. Smoking should be represented by how many
cigarettes per day, or if a pipe or cigar smoker, again how many each day. Alcohol should
be represented by either the number of standard drinks per day, or in grams of alcohol.
There is no shortage of dosage guides which will help you to calculate or at least
guesstimate the daily consumption. Being the pure hearted angels that medical students
are, I am sure many of you will have never imbibed of the devils nectar, in which case it
might be useful for you to speak to your colleagues, who do drink, for some guidance on
the accepted vernacular for drinks. Such terms as Super or Heavy are widely accepted
terms for full strength beer. Unleaded as well as any number of derogatory, somewhat
socially intolerant terms may be used for light beer. It is also useful to understand the
differences between stubbies, tallies, middies, schooner, and jugs. With regard the illicit
drugs, there is again no shortage of colloquialisms for the various drugs available. Indian
Hemp, Sweet Mary Jane, Wacky Tobbaccy, Herbal Ciggies, Joint, Spliff, Head, Skunk,
Pot, Herb, Reefer, Weed, Grass, Bud, Dope, Homegrown, Ganja are just a few variations
on Marijuana Products. Although not universal, it is at least a tendency that your ease
with the vernacular is likely to help the patient feel more comfortable with sharing their
illicit drug history.
Remember, the patient does have a right to privacy, ask the question, and accept the
answer. Patients do not need to reveal everything to you, however the more that we go
out of our way to make them feel at ease, and reassured by our professionalism, the more
they will be happy to speak to you about very private matters.
Also don’t get concerned when a patient has told you one day that they have never used
illicit drugs, and the next day you are present when they tell your boss a substantially
different story with a great deal of detail. Sometimes people need a little time to feel safe
enough to let strangers into their world.
The History – Systems Review

This is possibly the section of the write-up which will most test your tolerance of
ambiguity. Early in the year, we will tend to expect verbosity, towards the end of the
year, we will hope that you have started to discern how much you need to say.
Very simply for each section of the systems review, I want you to list positive findings
first, then negative findings. If positive findings are in the middle of a long list of
negative findings it will be easy to miss. Apart from that, it is simply system by system as
laid out in Talley & O’Connor.
The Examination

The first two sections that should appear in your examination, is the end of bed
description, and the vital signs.
The end of bed description is normally one or two sentences which would describe the
patient and their immediate environment. For example:-
Mr Smith was sitting on the edge of his bed, leaning forward, breathless at rest, only able to speak in short sentences. He has oxygen running at 2lt/min by nasal prongs, and the sputum mug contains green phlegm.
The other point to be made at this stage is to do with a comment on ethnicity. If you do
not believe that ethnic origin has any impact on this patient’s diagnosis or management, I
am happy if you simply refrain from specific comment (as per the example above), if you
do feel it appropriate to make comment on ethnicity, I will ask that you do so accurately.
Two of the most common mistakes relate to the use of the terms Indigenous and
Caucasian.
Indigenous - If your patient is an Indigenous Australian, they are either an Aboriginal
person or a Torres Strait Islander, or they are of both Aboriginal and Torres Strait Island
descent. Indigenous Australian describes two distinct ethnic groups, so if your patient is
an Indigenous Australian, please be specific. When you write the terms Indigenous,
Aboriginal or Torres Strait Islander, you will use capital letters in doing so. A lower case
‘i’ is acceptable if you are talking about an indigenous plant, but not for people.
Caucasian - I know that you have seen the overuse of the archaic anthropological term
‘Caucasian’ endlessly throughout your time at medical school. If you are referring to
race, do not use this term, as the anthropologists have acknowledged its lack of meaning
some time ago. If you are referring to an ethnic or geographical area of origin, this is the
accepted use of the term today. Below you will find a map of Caucasia (Georgia,
Armenia and Azerbaijan.) so if you must use this term, please do so correctly. Just
because you have heard a doctor use a term, does not mean they have used it correctly. It
is good that you are respectful to your seniors, but it should not interfere with your
objectivity.
When making reference to the patient’s sex, I would prefer the human terms of boy, or girl, man or woman, gentleman or lady. I do not like the terms male or female, as I find them dehumanising. There is a habit which develops in medical school to use words which make us sound objective and distant. However, I would prefer that you elect to ‘be’ objective over ‘appearing’ objective, and there is already enough distance between ourselves and our patients in accepting the fact that they are the one in the room with the pain, I do not see the need to add further distance between us, and the people on whose behalf we have committed our lives to advocate. The end of bed description should then be followed by the patient’s vital signs with the units of measure. Heart Rate (in beats per minute, bpm), Respiratory Rate (in breaths per minute, bpm), Blood Pressure (in mmHg, lying and standing if there is any concern about the patient’s fluid status, or sympathetic compensation for posture), Temperature (given in ºC, with a note regarding the method of measurement, eg tympanic, oral mercury, oral electronic, per axillae electronic), Height (in centimetres or metres, if you don’t have the facilities to measure their height, at least check to if they possess a driver’s licence, which will have the height recorded), Weight (in Kilograms, you should be able to have access to a set of scales in the hospital, alternatively if the nursing staff have measured the weight during this admission, you may use that data) and take a brief moment to calculate the patient’s BMI now that you have weight and height. If a blood sugar level (in mmol/l) is available and the patient circumstances suggest it (e.g. Diabetes Mellitus, dizziness, loss of consciousness) you ought to record it. Also consider a Urinanalysis (dipstick) if clinically indicated. If your patient is a respiratory or cardiac patient you may wish to note the Oxygen Saturation (in percent). If you do make record of the oxygen saturation, make sure you also make note of the inspired oxygen (e.g. on Room Air, or 2lt/min oxygen by nasal prongs, etc) Between the end of bed description and the vital signs, the reader will be able to gain a good overall picture of the patient, as well as being able to perform their own mental triage regarding the patient’s overall condition and stability. In your early years as a doctor, when calling your consultant, this information will help your boss make an assessment about the urgency of treatment with this basic information. From here you will need to start with your specific systems physical examination. Each major body system will start with the hands, moving up the arms, to the head, down to the neck and then the rest of the system. I would recommend that you coalesce all of the hand, arm, head and neck findings (with the exception of the Cranial Nerves) into a single section, then split into the specific systems groups. There is a tendency to copy out all of the eponymous nomenclature (stuff that is named after somebody) from Talley & O’Connor as a way on convincing the tutor that the student has carried out a thorough examination. Make sure that if you are going to copy out all of these names into your record of examination that you at least know what each of these signs actually mean. Should I subsequently find out that you have simply copied out a term, without any understanding of what it might mean, you ought to expect to have this reflected in your marks.
As a routine in each of the body system examinations you will go through, inspection,
palpation, percussion and auscultation. Try not to break the order, using a universal order
is for two reasons, it is a simply way of breaking up the examination so that the examiner
does not forget specific subsections, and it is also more efficient to use a universal
method of recording signs which will make it easier for other members of the team to
locate specific parts of the examination.
Over time, I have noted some specific idiosyncrasies in our JCU students’ record of the
physical examination.
JVP – has frequently been reported by students to be slightly raised, or sometimes
absent. The examination is the objective or measurable part of your assessment of the
patient, if the JVP is raised, you ought to say by how much (in cm). If at a 45º incline, the
JVP is not visible, it is ‘Not Raised’, if you are concerned that you are not expert enough
to see it, try changing the degree of elevation of the patient. You could lower the patient
to 30º or even lay them down flat, and see if the JVP becomes more apparent at that
point, although there is no need to record these details, it might be a way for you to gain
confidence in what you are looking for.
Heart Sounds – should be reported in terms of normal 1st and 2nd sounds, 3rd or 4th
sounds which might be present (and are by nature both abnormal), and rubs or murmurs.
Murmurs are described as systolic or diastolic, you may use terms such as ‘Pan’, ‘Mid’,
or ‘crescendo-decrescendo’ to give a further explanation. When it comes to ‘intensity’ or
‘loudness’ they are always reported on a scale of 1-6. 1/6 barely audible (usually only
heard by the consultant), 2/6 audible but with difficulty (you will still often need the
room to be quiet), 3/6 easily heard, 4/6 easily heard with a palpable thrill, 5/6 very loud
with palpable thrill, 6/6 heard from the end of bed without need for a stethoscope (then
kindly and respectfully ask the patient if they might be so gracious as to allow you to
bring some of your colleagues to hear their interesting murmur).
Pulses – Rate, Rhythm and Nature. If you are unable to palpate the pulse, it is recorded as
impalpable. Although it is admirable for you to acknowledge your own lack of
experience (eg I could not palpate the pedal pulses), you ought to state the objective
‘Impalpable’. This is more important when you have longer relationships with patients,
and need to know that the impalpability of a particular pulse is a new or old finding.
Pemberton’s Sign – the patient is asked to raise both arms above their heads, as high as
possible (Pemberton’s Manoeuvre), whilst the practitioner observes for the development
of facial plethora, venous distension and stridor. A positive Pemberton’s sign indicates a
thoracic inlet mass, such as a retrosternal goitre, or a tumour, such as a tumour of the
thymus. This is indeed a part of a routine Respiratory examination, but if the student has
not performed the basic Inspection, Palpation, Percussion and Auscultation, I tend to
become suspicious that they have recorded looking for this particular sign simply because
it is eponymous nomenclature, and makes the student appear clever for being able to
speak of a rare sign.

Gynaecomastia – when broken down the word literally translates to woman’s (Gyne)
breasts (mastos). Therefore if you are checking your female patient’s for Gynaecomastia,
you are guilty of performing a TUBE (Totally Unnecessary Breast Examination), which
will require immediate referral to the Dean of Medicine, to investigate possible
professional misconduct.
Although there are all kinds of simple mistakes that can be made in your examination,
these are the common errors in the student assignments over the last few years. You are
to perform a full head to toe examination, we are aware that in first term you will have
limited expertise in examining the systems you have not yet studied, but nevertheless the
more practice you have, the better you will get at examination skills.
Diagnosis – Provisional Diagnosis

Given that our profession is a diagnostic profession, if the admission does not end with a
Diagnosis, we simply have not earned our keep. Up to this point, the information
provided in the history and examination ought to lead the reader to the same conclusion
as you regarding the provisional diagnosis. The Provisional Diagnosis should be the most
likely diagnosis given the information available at this point (after history and
examination). If your patient has a final diagnosis of Biliary Colic, but the history and
examination is more suggestive of Peptic Ulcer, and the final diagnosis was only reached
after the investigations, your Provisional Diagnosis ought to be Peptic Ulcer.
Diagnosis – Differential Diagnoses

You will possibly find some variation from tutor to tutor, as a general rule of thumb I
believe the differential list ought to include the next one or two most likely conditions
which might mimic this presentation, with consideration to any more rare conditions
which will have serious consequences if missed. If as discussed earlier in this document,
you have elected to write your case as a Management Case, instead of Provisional and
Differential Diagnoses, you may instead note primary and secondary diagnoses, you will
however, be expected to offer a greater depth in your management plans for the patient.
Investigations

Your investigation list should revolve around those investigations which will help to
prove the Provisional Diagnosis and exclude the Differential Diagnoses. As a rule in
clinical medicine you should not perform any test, if its outcome will not alter your
management. You should consider giving an explanation for each investigation, as to
how it will contribute to solidifying a diagnosis. By all means, if you truly feel the
reasons for the investigation are self evident, you do not need to give an explanation, but
if I cannot see the direct logic of performing a test, it will help you in your marks to have
been able to give a sensible justification for the test in question.
Problem List

This is not an essential section of your case write-up, however if your patient does
happen to have multisystem disease, or if they have significant social, economic and
cultural barriers to management of their problems, it might help to have formulated such
a list, as a precursor to developing a management regimen.
If you have found other problems previously not diagnosed or addressed, this will give
the springboard for you to make specific note of these issues, and then lead into the
management plan. From time to time students have turned up important findings in their
systems review, only to then ignore these issues in their conclusion. The only thing worse
than missing a diagnosis, is making one, and ignoring it.
Management Plan

This may take slightly different forms depending on the patient. Should the patient have
multiple medical issues you may list your management plans starting with the most
pressing condition, and moving steadily down the priority tree. Alternatively, you might
start with those things which will be easiest to improve with the greatest benefit to the
patients overall circumstances, working your way to those things which will be hardest to
change, or will yield the least benefit in doing so.
If the patient has single system disease, or only a few other well controlled conditions,
you might elect to deal with your management plan in terms of immediate actions (or
those things which need to be initiated before leaving the Emergency Department),
actions for the next 24hrs, this might include such things as a decision to operate on the
patient, or transport the patient to a larger facility, then those things which may be issues
over the next weeks or months.
The most common error I have seen by students is to ignore important issues which they
have uncovered, which might be seen as separate to the presenting condition. Remember
it is our duty to care for our patient, NOT care for a disease, in which case we take on the
responsibility of all health and related issues which will affect our patient returning to the
best possible health.
The Referral Letter

The referral letter accounts for 40% of the total assignment marks, so it would seem
reasonable to expect 40% of the effort to go into the letter. A quarter of the referral letter
marks (or 10% of the total assignment marks) is allocated to the setting out and overall
appearance of the letter. Those of you who could not be bothered with taking the time to
set the letter out in a professional manner are throwing away easy marks.
Take some time to create your own letterhead, it may contain humorous references if you
do desire, as long as these to not detract from the fact that you are in a remote location.
An example of such silliness would be the students who have for the sake of the letter
pretended that they are located in Brisbane, and are referring the patient to a service in another capital city. This does nothing to reflect the student’s appreciation for the unique difficulties in organising a referral from a remote area. Take the time to find some appropriate artwork to enhance the letterhead, many of you will eventually need to design the letterhead of your own practice, so this is a good opportunity to give some consideration as to what effort should go into the creation of the letterhead. The selection of the font, and the font size along with the overall setting out are all things which you should give some time and consideration to. If you elect to use a more classically recognisable emblem of healthcare, I would take this moment to remind you that the Staff of Asclepius is the ancient emblem of our profession, not the Caduceus, which is the staff of the Greek god Hermes, and later the Roman god Mercury. Hermes is the messenger of the gods, and he and his staff are associated with wealth and commerce. Hermes is also the patron of thieves and tricksters. Needless to say, you will commonly find the Caduceus on North American health emblems. So if you wish to pay homage to Greek mythology when selecting art for your letter, feel free to do so, but please get the mythology right. After your own letterhead is completed you will need to have the full address of the practitioner or service you are referring the patient to. By all means be humorous, however make sure that the practitioner to whom you are referring the patient is appropriate both in terms of the patient’s needs and geography. After the opening of ‘Dear Dr …’, you will then have the ‘re’ statement, which will have the name and date of birth of the patient. If you are referring your patient to a public outpatient service, you will need to include address details of your patient so that the letter notifying the patient of the subsequent appointment can be sent to them. Of course you would need to use a fake address, but I would recommend that you make the address in the same town of their origin so as to keep some degree of authenticity. It will make the letter look a little neater, if you use a Bold font for the ‘re’ statement, and use the ‘Center’ alignment for the statement (And for those of you paying attention, you will note the US English spelling has been used for the word ‘Center’, this is because it is the name of the virtual button in the ‘Word’ program, which is also why it appears within inverted commas). The letter is in many ways a summary of your admission notes. You will need to go over the reason for presentation to your service, the significant examination findings, significant investigation findings and your diagnostic list. Their past medical history and medication history should also be included in the letter. You should make sure that the request you are making of the receiving practitioner is clearly stated. If the letter is referring your patient back to their Primary Practitioner (their GP, or Remote Area Nurse) you should clearly state what follow-up requirements will need to be taken care of by the Primary Practitioner, as well as any details relating to subsequent follow up appointments the patient might have with your service. If you are referring the patient back to the Primary Practitioner, please also remember to clearly state under what circumstances you feel the patient needs to return for further acute care. If you do have a well presented letter, which you would like to be printed in colour, just email it to Ms Stephanie King, and respectfully ask her to obtain a colour print of your letter. Well this is pretty much the collective wisdom I have to offer for your assignments. As a final suggestion, please do get your colleagues to proof read your assignment for errors in spelling, grammar, overall presentation and logic before you hand it in for marking.

Source: http://www.micrrh.jcu.edu.au/Education/Medical/Louis-case-writeup-guide.pdf