Read the case notes and complete the writing task which follows.

Notes:

Assume that today’s date is 15 May 2021.
You are a physiotherapist in Stillwater Physiotherapy Clinic. Mrs Abrams is a regular patient at your clinic.

PATIENT DETAILS:

Name:                                 Mrs Doris Abrams
Address:                            840 Oceanview St, Stillwater
DOB:                                    03 Apr 1986 (35 y.o.)

Social background:

• Married – husband James Abrams
• Sport – plays netball once/week
• Hiking once or twice/year
• Magazine editor (full-time)

Family history:

• Rheumatoid arthritis (RA) – maternal uncle & grandfather

Medical history:

• 2019 Shoulder dislocation
• 03 Jan 2021 Wrist sprain (right)

Weight:                                      55kg
Height:                                       165cm
BMI:                                             20.2 (healthy)

Current medication:            None

Treatment record:

03 Jan 2021

Presenting complaints:

• Pain in R wrist. Suspects injured during netball game 2 days ago
• Dull pain, mostly at night, difficulty sleeping

Physical assessment:

• Swelling R wrist
• Some pain on flexion

Diagnosis:

• R wrist sprain

Treatment:

• Rest, ice, exercises, Tubigrip (elastic compression bandage)
• Review in 1 week

10 Jan 2021
Progress:     ↓swelling

Recommended treatment:

• Resistance exercises with bands (gradual start to regain strength)
• Return to training – in 1 week if comfortable
• Pt to contact practice if injury not settling as expected

15 May 2021

Presenting complaints:

• Dull aching pain – in fingers, occasionally feet, not related to activity, varies in presentation
• Sleep – disturbed by aching in hand/feet joints at night
• Morning stiffness – lasts at least 1hr
• Fatigue (unusual for her)
• Pt reports ↓appetite & weight loss (↓2kg)

Examination:

• Hands & feet – joints warm & red-looking
• Pain on resisted grip testing of hands
• Gait in bare feet – compromised by discomfort

Possible diagnosis:
Rheumatoid arthritis (RA)
Discussion:

• Pt reports previous concern re possible RA risk (family history)
• Pt agrees to see usual GP (Dr Rahimian) – will return to physio for further education & management if diagnosed with RA

Treatment:

• GP review for further investigation – blood tests & X-rays as necessary

Writing Task:
Using the information in the case notes, write a letter to Dr Rahimian informing her of your suspected diagnosis and
requesting further investigation. Address the letter to Dr Sara Rahimian, Stillwater Private Practice, 124 Main Street,
Stillwater.

In your answer:

• Expand the relevant notes into complete sentences
• Do not use note form
• Use letter format

The body of the letter should be approximately 180–200 words