The task
Original independent practice. All patient findings and arrangements are fictional case facts, not general clinical recommendations. Allow 45 minutes: 5 minutes for reading and 40 minutes for writing. Assume that today is 3 November 2026. Mr Shammas has attended your general practice to discuss his latest results.
You are Mr Riad Shammas's general practitioner. Using the case notes, write a referral letter to Dr Heba Makhlouf, Consultant Nephrologist, Renal Outpatient Clinic, 26 Clinic Road, SW1A 2AA, requesting investigation of his chronic kidney disease and persistent proteinuria, with advice on further management. 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.
Length: the body of the letter should be about 180–200 words. You have 45 minutes in the test: 5 minutes to read, 40 to write. Letter type: Referral letter.
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Which case notes belong in this letter?
Chronic kidney disease with persistent proteinuria: referral
You are Mr Riad Shammas's general practitioner. Using the case notes, write a referral letter to Dr Heba Makhlouf, Consultant Nephrologist, Renal Outpatient Clinic, 26 Clinic Road, SW1A 2AA, requesting investigation of his chronic kidney disease and persistent proteinuria, with advice on further management. 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.
Mark every line: Include keeps the specific detail; Compress keeps the relevant gist in fewer words; Omit leaves it out. Then compare your choices with our reviewed analysis. Some choices are optional.
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One-page worksheet. Answers and reasons are on the linked webpage, so you can practise before checking.
Case notes
Patient details
- Name: Mr Riad Shammas
- DOB: 18/02/1970 (56 yrs)
- GP review: 03/11/26; renal abnormalities first identified April 2026
Social background
- Office administrator; works regular daytime hours
- Lives with partner; independent with daily activities
- Enjoys photography; recently bought a camera
- Complained waiting-room chairs were uncomfortable and staff seemed unhelpful
Medical history
- Childhood tonsillectomy; no ongoing complications
- No diagnosed diabetes or hypertension; no previous renal diagnosis; no stones or recurrent urinary infections
- No known family history of renal disease
- No regular medication; no known drug allergies
- Denies NSAIDs, herbal remedies or bodybuilding supplements
Serial investigations
- 06/04/26: eGFR 58 mL/min/1.73 m²
- 06/07/26: eGFR 54 mL/min/1.73 m²
- 26/10/26: eGFR 51 mL/min/1.73 m²
- 06/07/26: urine ACR 78 mg/mmol
- 26/10/26: repeat early-morning urine ACR 86 mg/mmol
- Both urine samples: clinically well; no recent strenuous exercise
- Urine microscopy: no haematuria; cultures negative on both occasions
- Ultrasound 29/10: normal-sized kidneys; no hydronephrosis or cysts; bladder unremarkable, no significant post-void residual
- HbA1c 26/10: 36 mmol/mol
- Potassium 4.5 mmol/L; serum albumin 39 g/L on 26/10
Current assessment
- Reports foamy urine for 3/12
- No oedema, dyspnoea, dysuria or visible haematuria
- Today: BP 128/78 mmHg; no peripheral oedema
- No rash, joint symptoms or recent intercurrent illness
- Assessment: CKD with unexplained persistent albuminuria; possible glomerular disease
Plan
- Refer nephrology: establish cause; advise further investigations and renal protective treatment
- Serial laboratory results and ultrasound report enclosed
- GP to continue renal function/BP monitoring pending specialist review
Who is reading, and what do they need?
Dr Makhlouf needs the evidence supporting a new renal referral for Riad Shammas, born 18 February 1970, following his 3 November review. Do not assume she has already reviewed his results. Supply the dated renal trajectory, persistent albuminuria, a concise account of previous investigations and selected relevant history, with a clear request for aetiological investigation and management advice.
What to include
Selection is the skill the Content and Conciseness criteria reward. These notes earn their place:
| Case note | Why it belongs |
|---|---|
| CKD with unexplained persistent albuminuria; investigate cause and advise renal protective treatment. | States the unresolved clinical problem and the decisions requested from nephrology. |
| eGFR: 58 in April, 54 in July, 51 on 26 October. | The earliest and latest results demonstrate the renal-function trend across more than three months; the July result is optional. |
| Urine ACR: 78 in July; 86 mg/mmol on repeat early-morning sampling in October. | Establishes albuminuria on separate samples rather than relying on a single abnormal result. |
| Both samples obtained while clinically well, without recent strenuous exercise; cultures negative, no haematuria. | Briefly summarise the urine findings. The sampling context is useful supporting detail that may be omitted. |
| Ultrasound: normal-sized kidneys; no hydronephrosis, cysts or significant residual; bladder unremarkable. | Provide a concise structural investigation summary. An unremarkable renal ultrasound is an acceptable compression; individual normal findings need not all be listed, and normal imaging does not exclude renal disease. |
| No diagnosed diabetes/hypertension; no previous renal diagnosis, stones or recurrent urinary infections; BP 128/78. | Select useful aetiological history and examination findings without inventing an established cause. The full negative history is optional. |
| No regular medication, known drug allergies, NSAIDs, herbal remedies or bodybuilding supplements. | These provide useful prescribing and exposure background. Select relevant details if space permits, preserving the recorded scope of any exposure denial. |
| Laboratory results and ultrasound enclosed; GP continuing renal function and blood-pressure monitoring. | Identifies supporting documentation and the interim division of responsibility. |
What to leave out or compress
| Case note | Why it goes |
|---|---|
| Office administrator working regular daytime hours. | The work schedule has no stated bearing on renal investigation or management. |
| Lives with partner; independent with daily activities. | There is no documented support or functional problem requiring action by the nephrologist. |
| Enjoys photography; recently bought a camera. | The hobby and purchase do not help explain the renal findings or guide the referral. |
| Complaints about waiting-room chairs and unhelpful staff. | Service complaints do not contribute to the clinical question or ongoing monitoring. |
| Childhood tonsillectomy without ongoing complications. | The resolved childhood procedure has no documented connection to the current renal abnormalities. |
| No known family history of renal disease. | This apparently relevant background can be compressed after stronger aetiological evidence if space permits. |
A paragraph plan for this case
Open with the request to establish the cause and guide management, followed by the dated baseline and latest eGFR results and both ACR measurements. Briefly summarise previous urine testing and ultrasound. Add selected history, symptoms, examination findings or supporting blood results where useful; there is no requirement to reproduce every relevant result or negative symptom. Finish with the enclosed reports and ongoing GP monitoring.
Where candidates slip on this task
- Use 6 April and 26 October for the baseline and latest eGFR results, retaining mL/min/1.73 m². The 6 July result is optional; do not invent an earlier baseline or rate of decline.
- Retain both ACR results and their mg/mmol units, identifying the repeat October sample as early-morning; do not treat July's collection timing as specified.
- Possible glomerular disease remains a working explanation; normal ultrasound findings, negative cultures, absent haematuria and the recorded HbA1c do not establish the cause.
No model letter is published here. Write for the named reader from the case notes in the timed editor, then get it marked.
Write it in the timed editor and get marked on the 6 criteria
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Your profession's guide: OET Medicine. Layout and structure: OET letter format.
Questions about this task
Should all the laboratory results be reproduced despite the enclosures?
No. You do not need to include every relevant result or finding. Retain the dated baseline and latest eGFR results, both ACR measurements, the unexplained persistent abnormality and the explicit diagnostic and management request. Briefly summarise previous urine testing and ultrasound; individual normal imaging findings need not all be listed. The intermediate eGFR, sampling context, HbA1c, potassium, albumin, foamy urine and detailed negative symptoms or history may be omitted. Choose useful supporting details within the word limit. Enclosures provide the full results but do not replace the core referral evidence.
Can the letter identify glomerular disease as the cause?
No. The assessment describes unexplained persistent albuminuria and possible glomerular disease. The referral asks nephrology to establish the cause and advise further investigations and renal protective treatment. Normal imaging and the listed negative findings must not be presented as proof of a particular diagnosis.
Sources
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