Ticket Id: 55383

Dr Max Simmons,
Neurologist
City General Hospital
Perth

07/06/2019

Dear Dr Simmons,

Re: Margaret Simon

DOB: 02/03/1961

I am writing to refer Mrs Simons, a 58-year-old sales clerk, for further assessment and management of Comment [teacher1]: Ms
suspected complex partial seizure epilepsy and management, possibly with surgery.

Mrs Simons, has been brought today having a seizure episode. She was fully conscious at that time. She Comment [teacher2]: Ms
used to clench her teeth, breathed heavily and felt aura of chilling sensation at the back (for 10-20 Comment [teacher3]: when she had
seconds) at the time of seizure. Her vitals, physical exam and RBS were unremarkable. An EEG and MRI Comment [teacher4]: in a public place
exams were ordered. Comment [teacher5]: had clenched
Comment [teacher6]: a
Past EEG and MRI exams were normal. The current medications include carbamazepine 600/400 mg B.D.,
lamotrigine 50/70 mg B.D., conjugated estrogen 1.25 mg PO q.d., thyroxin 100 mcg PO q.d. and
sumitriptan P.R.N.

Mrs Simons lives with her mother. She had her first episode of convulsion at the age of two, when she had Comment [teacher7]: Ms
a febrile illness. The seizures were started to present with visual aura, when she was in grade three. She Comment [teacher8]: with
has been getting 3-4 seizures/month for the previous few years, although she has been taking Comment [teacher9]: started
anticonvulsants.

Past EEG and MRI exams were normal. The current medications include carbamazepine 600/400 mg B.D.,
lamotrigine 50/70 mg B.D., conjugated estrogen 1.25 mg PO q.d., thyroxin 100 mcg PO q.d. and
sumitriptan P.R.N. There is no history of any kind of substance abuse.

Mrs Simons also has migraine, which is not frequent. Her past surgical history includes partial Comment [teacher10]: occasionally
thyroidectomy. One of her cousin died, at the age of 12, with a history of grand mal seizure. Comment [teacher11]: seizures

Your specialist advice would be highly appreciated regarding her possible complex partial seizure
secondary to mesial temporal lobe epilepsy.

Yours sincerely,

Doctor

Report

Word length 220

Comments The letter has many inaccuracies pertaining to
grammar and word choice. Information could be
written in a better way at a few places. However,
all case notes are covered and the purpose is laid
down well. Overall, the letter falls short of meets
the expectations.

Estimated Grade C+
Advice 1. Revise grammar.
2. Improve choice of words.
3. Read case notes carefully.
4. Improve coherence.
5. Always proofread the letter after finishing it.
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