Time Allowed

Reading Time: 5 minutes

Writing Time: 40 minutes
Read the case notes below and complete the writing task, which follows:
Notes
Mr Brian Alvarez, a 42 years old patient in your general practice
Patient History
Allergic to penicillin
High pain tolerance
Taking iron supplements, multivitamins and caffeine pills
Surgery for torn ACL in 2005
Broken clavicle in 2008
Car accident resulting in neck and lower back pain in 2010
Social History
Married, no children
Works as janitor
Plays tennis every two weeks
20/12/13
Subjective
Tingling sensation in left arm and hand
Occasional pain on left shoulder blade that irradiates to arm and neck
It has been presenting for the last 2 weeks
Pain can be relieved with painkillers
Review in 1/12
Objective
Poor posture with slouching
Muscle presents inflammation
Assessment
Muscle strain
Plan
Pt was advised to rest and stop repetitive physical activity
Suggest muscle training therapy for long-term improvement
Ibuprofen 400mg p.r.n
15/01/12
Subjective
Pain has stopped
Pt will go back to usual activities
Training therapy was not needed
Objective
No inflammation

Muscle feels supple

Assessment
Successful recovery
03/02/12
Subjective
Severe scapular pain that irradiates down to left arm present at all times
Numbness in left hand
Pt has suffered from migraines in the last week
Pain is not relieved by over-the-counter painkillers
Objective
Area presents inflammation
X-rays show no fracture
Assessment
Suspected compressed never in left scapula
Writing Task
Write a referral letter to orthopedist Dr Melvina Cornell at the Trauma Department of Glasgow Royal Hospital, 84
Castle Street, Glasgow, Glasgow City.
In your letter:
Expand the relevant case notes into complete sentences.
Do not use note form.
The body of your letter should be approximately 180 ~ 200 words.
Use correct letter format.