Writing : Dentists : Practice 1 : Case Notes & Writing Task

Anna Gonzales is a patient in your dental practice. Read the case notes
below and complete the writing task that follows.

Time allowed: 5 minutes reading time (no writing), 40 minutes writing

time.

CASE NOTES

Name Anna Gonzales

6/92 Perry Street
ST ALBANS VIC 3198
Tel: 9482 1732
Born: 07.09.1941
Reason for Replacement of worn and discoloured partial dentures
presenting
Dental history • extractions
• fillings
• dentures
• Scale and clean (not often)
• No orthodontics
• Removal of white patches and lumps and ¼ of the tongue –
recently. Was told it was cancer.
Medical history • Has had 5 children
• Asthma problems, mild
• Heavy smoker of cigarettes. Was told that this probably
caused cancer on tongue.
Family & Social Born in Chile, migrated here 1996. Widow, living by herself.
history Not sought dental care on a regular basis. Has attended this
clinic since 2006.

Examination • MoD Amalgams in 17, 14, 27, 38, 47

13/05/06 • MO Amalgam in 48
• All other posterior teeth are missing
• Much supragingival calculus on lower anteriors
• Carious lesions 12, 22, 23
• Anterior teeth having small fillings 11, 21, 13
 • Partial upper denture, partial lower denture – both acrylic
Treatment record
01.06.06 Gross scaling. Oral hygiene instruction commenced
08.06.06 Fine scale all teeth. Cleaned with coarse paste. Continued
instruction.
16.06.06 12 M 1.5ml prilocaine. CaOH cement. Composite resin,
shade U
08.07.06 22D and 23M. 2ml prilocaine. Fairly deep in 22. CaOH
cement in both. Composite resin. Shade U.
16.07.06 Cleaned teeth and final instructions on oral hygiene.
25.07.08 Requested replacement partial dentures. Examination
disclosed white patches on left border of tongue. Referred for
oral pathology examination.
02.08.08 Consultation with oral surgeon, and patient booked into
hospital.
13.08.08 Partial resection of tongue (with white patches). Pathology
examination at time of operation showed neoplasia.
17.08.08 Confirmatory report of sectioned tissue that was removed.
Carcinoma.
13.11.08 Patient presented requesting replacement, partial dentures.
Primary impressions in alginate. White spots apparent on left
side of resected tongue.

WRITING TASK

Using the information in the case notes, write a letter of

referral to the oral surgeon at whose clinic the patient
previously attended. The letter should be 180 to 200
words long. Address the letter to: Mr T L Murphy, 321
Elizabeth Street, Melbourne 3000.

DO NOT use note form in the letter; expand the case

notes where relevant into full sentences.
Some notes on my feedback.
The highlighted colours in the feedback (right) column refer to those parts of your letter highlighted with
the same colour; where I have crossed out your text, I am suggesting that that text is unnecessary; where I
have added text in parentheses/brackets I am suggesting that additional text is needed to improve your
original. Please note that my comments will very often focus in some detail on the finer points of grammar and
vocabulary. This is intended as language teaching–if there are a many comments, it could simply be that there is
a repetition of a minor error that might not affect your test score.
Mr T L Murphy 97 words in the original
13 November 2008 Main point of the referral clearly identified
321Elizabeth Street and focused on. Good first effort and close to
Melbourne 3000 a pass, but some useful information missed
Dear Mr Murphy, and some small vocabulary and grammar
Re: Anna Gonzales D.O.B 07/09/1941 issues.
6/92 Perry Street This sort of detail is unnecessary in the
ST ALBANS VIC 3198 letter.
Tel: 9482 1732

Mrs Gonzales reported at my surgery
today, 13/11/2008 for replacement of her
partial dentures. On examination there
appears white patches on the left side of
her tongue.
Mrs Gonzales had undergone (underwent)
partial resection of her tongue, and was
reported (for what was later confirmed as)
cancer, of the tongue on13.08.08. She has
not made any further appointment with
you afterwards, and I am much concerned
about the recent developments on (in) her
mouth.
You can delete the final –s because the
following nouns is plural (i.e. no final –s on
verbs when used with plurals).
Simple past tense is better here because you
are referring to a particular event on a
particular day rather than a period of time in
the past (for which the past perfect that you
have used would be used).
I suggest this change to try and make it
clearer that the cancer was actually
confirmed–the use of reported is less
definite (i.e. it might have been reported but
later been found to be absent).
These are redundant/unnecessary i.e.
1. we can assume the cancer is of the
tongue because that is what has been
operated on, and
2. the earlier use of present perfect
tense and or further indicate that you
are referring to the time after the
operation.
Preposition choice. (The use of on would be
 OK if used with her tongue.)
NB A more general point: the notes make
clear that Mr Murphy is the surgeon who did
the resection so it would be useful to remind
him of this–this would require a change such
as: You may recall that your performed a
partial resection of Mrs Gonzales’ tongue,
for what was later confirmed as cancer, on
13.08.08. She has not …
Could you please examine, diagnose and
treat the patient as you think appropriate.
I shall defer further treatment of partial
denture, until I hear from you.
Thank you for seeing Mrs Gonzales for
me.
Yours sincerely,
Anilkumar Vattekad
Mr. T L Murphy
321 Elizabeth Street
Melbourne 3000
13th November 2008
Dear Mr Murphy
Re: Anna Gonzales, D.O.B. 07.09.1941
I am writing to refer our mutual patient Mrs. Anna Gonzales to you who is suffering from
white spots on the left border of her partially resected tongue.
Mrs. Gonzales presented at my surgery today requesting replacement of worn and
discoloured partial dentures. Clinical examination shows apparent recurrence of white
spots on the left side of the partially resected tongue. As you know, the partial tongue
resection was done three months ago. Carcinoma of the sectioned tissue was confirmed
by pathology report. You would also be aware that Mrs. Gonzales is a smoker, which was
discussed as a probable cause of her tongue cancer.
I think Mrs. Gonzales has not had a follow-up appointment with you for a quite some
time and I am concerned about her tongue's current appearance. I would appreciate your
assessment and management of this patient. I am going to delay further appointments for
the partial dentures until I hear from you.
Please do not hesitate to contact me if you need any further information.
Yours faithfully
Xxxxx