Mrs. Larissa Zaneeta is a patient in your general 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 Mrs. Larissa Zaneeta Age 38-years-old Family and social history

Marketing manager, married, one child (four-year-old boy).

Medical history

Unremarkable, no medications

11/07/05

Complains of tiredness, difficulty sleeping for 2 months due to work stress Plans another child in 12 months, currently on oral contraceptive pill (OCP)

O/E: Appears pale, tired and slightly restless BP 140/80 No abnormal findings Assessment: Stress-related anxiety Plan: advised relaxation techniques, reduce working hours, prescribe sleeping tablets tds

15/08/06 Stopped OCP 4 months earlier, still menstruating Worried Sleep still difficult, work stress unchanged, not possible to reduce hours O/E: Tired-looking, slightly teary Assessment: Work stress, growing anxiety failure to conceive Plan: discussed nature of conception takes time, patience discussed frequency sexual intercourse discussed methods temperature / cycle

18/01/07 Expressed anxiety re failure to conceive, says she's "too old" sleep still a problem O/E: crying, pale, fidgety Vital signs / general exam NAD Pelvic exam, pap smear Assessment: as per previous consultation Plan: 1-2 Valium b.d.

Suggested she re-present next week accompanied by husband.

25/01/07 Mr. Zaneeta very supportive of having another child No erectile dysfunction, libido normal Mrs. Zaneeta unchanged O/E: Mr. Zaneeta normal Plan: Check Mr. Zaneeta's sperm count

02/02/07Sperm count normal Plan: Refer for specialist advice

WRITING TASK

Using the information in the case notes, write a letter of referral to Dr Elvira Sterinberg, a gynaecologist at 123 Church St Richmond 3121.

DO NOT use note form in the letter; expand the case notes where relevant into full sentences. Dear Doctor, Thanks for seeing Mrs Larissa Zaneeta, a 38-year-old marketing manager and a mother of four-yearold boy. She came to see me on 11.7.05 complaining of difficulty in sleeping and tiredness for 2 months.

Although she was taking ocp, she wanted to have a baby in a year. When I examined, she looked pale, tired and restless but other systems were normal. I diaganosed as stress-related anxiety and advised her to pracitse relaxation techniques, to reduce working hours and to take sleeping pills three times a day. A year later, there was no improvement in her condition and it was difficult for her to reduce working hours. In spite of stopping ocp for 4 months, she could not concieve. On examination, she seemed to be tired and slightly teary. I explained detail nature of conception: time, frequency and methods of intercourse. On her next visit after 5 months, she failed to conceive and still had a problem of anxiety and sleep. Physical examination was all normal except low mood, So, I gave her 1-2 valium two times a day and asked her to come again with her husband. On 25.1.07, assessment of her husband's sexual function-erection and libido- were normal. I recommended to do sperm count. Today, her husband's lab result turns out to be normal. Therefore, specialist advice is needed for them. I would appreciate your advice and further management plan for this couple. Yours Sincerely,