Trudy Mchugh
Dr Fransiska Hutahaean
87 George Town Road NEWNHAM, TAS 7248
29-01-1989
Dr B Aritonang
Surgeon
Launceston General Hospital
LAUNCESTON, TAS 7250
Dear Dr Aritonang
I am referring Mrs. Trudy Mchugh, 38 years old, who first came to see me on 27/01/1989 with the major complaint of abdominal pain in the left lower quadrant of her abdomen. The pain was sharp, constant and worsened while sitting up, walking or bending.
Examination has shown that she was not distressed. The blood pressure was 140/80 mmHg. The heart rate was normal and regular. There was tenderness on light palpation of her left lower abdomen and a vague mass as well.
She has had a spontaneous abortion in January 1989[i] and previous history of ovarian cystectomy and appendectomy. Her last period was in November 1988 and she is still breastfeeding her 3 year old child. Therefore I ordered a B-hCG test to exclude another pregnancy.
Further investigation has shown that she was moderately distressed. The pain worsened after eating tonight. She still had no bowel action or flatus for 3 days. The blood test has revealed that she had anemia. There was a tension in her abdomen and no bowel sounds. I diagnose her as having an Early bowel obstruction due to diverticulitis or carcinoma.
I would appreciate your assessment and further treatment of this patient’s condition.
Yours sincerely
Dr Fransiska Hutahaean
General Practitioner
[i] she has had a spontaneous abortion – present perfect for some unspecified time in the past or
She had a spontaneous abortion in January 1989- past simple for a specific date.
Note also that you use ‘in’ with a month e.g. in January and ‘on’ for a date e.g. on 21st January.
Probable grade: B+ / A-
Corection by Kay, the corrections are in the bold.
http://adrive.com/public/fe1c49dd5edddc1279f4cd8cfbedff24c931b1c74c1dc1c8496fa02ca7f369a4.html
