11 Baker’s Street
(Today’s date – April 2018)
Dear Dr. Janet,
Re: Mr. Jones, DoB 05 January 1972.
Thank you for seeing Mr. Jones, a 46 years old plumber, who has been smoking 20 cigarettes a day for the last 20 years and is experiencing from progressive breathlessness during the past few days. (Organise the contents of body paragraphs before deciding on possible reason and most important issue.)
Though Mr. Jones does not feel chest tightness on exertion and has no fist clubbing, further examination revealed that he has abundant tar staining. Moreover, auscultation revealed crepitation at left base. His systolic blood pressure is 108 mm Hg and diastolic blood pressure is 88 mm Hg. While his pulse is hard to feel, it has Sinus rhythm. Since 2014 he has been experiencing smoker’s cough without blood and wheezing. He also has a high hemoglobin level. (Write the recent symptoms and examination by connecting them in the right order of chronology and importance through proper cohesive devices.)
My provisional diagnosis is that he is suffering from lung carcinoma. However, his father suffered a cardiac arrest and his high hemoglobin suggests the possibility of Stenosis. Therefore, I am referring him for further investigation. (Justify why you’re referring.)
If you require any further information, please do not hesitate to contact me.