# Writing Case Notes

Read the case notes and complete the writing task which follows.

---

## **Notes:**

**Assume that today's date is 6 June 2024.** You are a GP at Central Medical Group examining Mrs Adriana Voss, a 45-year-old patient.

### **PATIENT DETAILS:**

* **Name:** Mrs Adriana Voss
* **DOB:** 18 March 1979 (age 45)

### **Social background:**

* Married, 2 children
* Part-time dental hygienist
* Non-smoker; minimal alcohol
* Gardening/piano increasingly limited

### **Family history:**

* Mother – RA (on methotrexate)
* Sister – Hashimoto's
* Father – T2DM

### **Past medical history:**

* 2015 – hypothyroidism (Hashimoto's), controlled
* 2020 – bilateral carpal tunnel syndrome, splint-managed
* 2021 – R shoulder impingement, resolved
* 2022 – iron deficiency anaemia, resolved

### **Allergies:**

* NKDA

### **Current medications:**

* Thyroxine 100mcg mane
* Ibuprofen 400mg b.d. p.r.n.
* Calcium + vitamin D daily

---

## **CONSULTATION HISTORY**

### **18 March 2024**

* **Presenting complaint:** Bilateral hand pain/stiffness x 3/12. MCPs and PIPs affected. AM stiffness 30–45 mins, eases with activity. Attributed by patient to CTS.
* **O/E:** Mild MCP tenderness bilaterally. Grip mildly reduced; no synovitis. Tinel's positive bilaterally (known CTS).
* **Investigations:** ESR 22, CRP 8 (mildly ↑). RF negative; TFTs WNL.
* **Plan:** ?Early inflammatory arthropathy vs CTS. Ibuprofen p.r.n.; night splints. Review 2/12.

### **6 June 2024**

* **Discussion:** Symptoms significantly progressed. AM stiffness now 1.5–2 hrs daily. Symmetric pain/swelling – MCPs, PIPs, wrists, bilateral MTPs. Difficulty walking in mornings. Grip worsening – considering reducing work hours. Unable to play piano; significant fatigue. Ibuprofen daily x 6/52 – partial relief only. No fevers, rash, or eye symptoms.
* **O/E:** Visible symmetric swelling MCPs 2nd–4th and PIPs 2nd–3rd bilaterally – boggy, warm. Squeeze test positive MCPs and MTPs. Mild wrist synovitis; no nodules.
* **Investigations:** ESR 38 mm/hr; CRP 24 mg/L (both ↑ from baseline). RF 86 IU/mL and anti-CCP 142 U/mL (both strongly positive). ANA negative. X-rays hands/feet: periarticular osteopenia MCPs, no erosions.
* **Assessment:** Highly suggestive of seropositive RA – symmetric small joint polyarthritis, positive RF/anti-CCP, raised ESR/CRP, AM stiffness >1 hr.
* **Plan:** Urgent rheumatology referral for early DMARD initiation essential to prevent erosion. Continue ibuprofen – GI risk advised. Steroids deferred to specialist.

---

> ### **Writing Task:**
>
> Using the information in the case notes, write a letter of referral to Dr Fiona McLeod, a rheumatologist at University Hospital, for assessment and management of Mrs Voss' joint symptoms. Address the letter to: Dr Fiona McLeod, Rheumatologist, University Hospital, 1 College Road, Westfield.
>
> **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**.


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Writing Risk Report

How it works

5 min — Read the case note

40 min — Write your referral letter

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What your report includes

Free OET MedicineWriting Risk Report

How it works

5 min — Read the case note

40 min — Write your referral letter

Instant — Get your Risk Report

What your report includes

Free OET Medicine
Writing Risk Report