LETTER 15

Dr Peta Cassimatis 

Psychiatrist 

1414 spaceLogan Road

Mt Gravatt,4222

10 February, 2010 

Ref :Mrs Alsion (SPELLING) Martin, 28 years 

Mrs Martin has clinical manifestations  that are suggestive of schizophrenia  and associated disorders. She requires further assessment and management from your health facility. 

• GOOD AND SIMPLE INTRODUCTION

In terms of  Mrs Martin’s social background, she Mrs martin  lives with her husband’s  parents she has she has a family history of schizophrenia. This sentence could have been combined with the next para

On first  September On 01 september,2010, Mrs Martin presented with poor health conditions associated  with  feeling tired tiredness, low grade fever  and loss of less interest at to work.On assessment,she was found to be nearly normal;  Therefore, she was encouraged to be relax, practice regular exercise and recommended to record her body temperature on temperature chart.

• Try to avoid writing long paragraphs

• Try to use same date format which u have used 

 On the next visit her subsequent visit, she stated she had domestic conflicts with her husband’s parents, together with  frequent headaches, difficulty in sleeping   and anxiety. Upon assessment , it she was noticed she had with poor eye contact and she was slightly depress mild depression .As a result of this Hence , 10 mg Diazepam  and paracetamol tablets were prescribed. supported  by Besides,she was given  both relaxation therapy and  counseling sessions .Also, she was and advised to bring her husband for the next visit.

• Giving importance for objective data would be highly appreciable

On consultation today, Mrs Martin’s husband  reported  Mrs Martin  shows  symptoms related to visual hallucinations and delusion for the last 5 days . she has also had low speech tone  concomitant with  impairment with her  planning abilities. On general examination,  it was asserted that she has low mood , bizarre behaviors  and  speech disarrangement . 

Today,Mr and Mrs Martine came to us.Mrs Martine has been seen with depressed mood,disorganised speech and bizarre behaviour along with no eye contact.as these signs are suggestive symptoms of schizophrenia and associated disorders,she is being referred to you for further assessment and management

In the light of the above, It would be appreciated if  you could  further management for Mrs Martin  from you health facility attend this case and do the needful

Yours sincerely, 

Dr:Ivan Henjak Dr Ivan Henjack

General practitioner.  General Practitioner

• You should give more importance for objective data rather than subjective data as the receiver wants to know about our findings.

• Organisation is okey but you should avoid irrelevant data

• Adding irrelevant data will ruin the beauty of letter

• Good luck !!!!!