The task
Original independent practice. Allow 45 minutes: 5 minutes for reading and 40 minutes for writing. Assume that today's date is 6 November 2026.
You are Ms Hagan's general practitioner. Using the case notes, write a referral letter to Dr Annie Deeley, Neuromuscular Specialist, Outpatient Neurology Service, 24 Clinic Road, NSW 2000, Australia. Request assessment and advice regarding possible myasthenia gravis, communicating the fluctuating symptoms, examination findings and pertinent negatives without presenting the diagnosis as confirmed. 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?
Suspected myasthenia gravis: referral
You are Ms Hagan's general practitioner. Using the case notes, write a referral letter to Dr Annie Deeley, Neuromuscular Specialist, Outpatient Neurology Service, 24 Clinic Road, NSW 2000, Australia. Request assessment and advice regarding possible myasthenia gravis, communicating the fluctuating symptoms, examination findings and pertinent negatives without presenting the diagnosis as confirmed. 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.
Download practice checklist (PDF)
One-page worksheet. Answers and reasons are on the linked webpage, so you can practise before checking.
Case notes
Patient details
- Name: Ms Kori Hagan
- DOB: 14/03/1992 (34 yrs)
- GP review: 06/11/2026; first neurology referral
Social background
- School administrator; afternoon computer work increasingly difficult
- Lives with partner; independent in daily activities
- Stopped driving voluntarily because of intermittent double vision
- Enjoys baking; entered local cake competition
- Reports sister's marriage difficulties; requests confidentiality
Medical history
- No previous neurological diagnosis or thyroid disease
- Symptoms began gradually 6/52 ago: intermittent R ptosis + binocular diplopia
- Worse with prolonged activity/late afternoon; ↓ after rest; often absent on waking
- Past appendicectomy, aged 15; uncomplicated recovery
- Regular medicines: nil; no known drug allergies
Current assessment
- Arms tire washing hair; improves after resting
- No persistent limb weakness, falls or neck weakness
- No dysphagia, choking, speech change or breathlessness
- No headache, eye pain, sensory disturbance or sphincter symptoms
- No recent infection; no weight loss
- Afternoon examination today: alert; comfortable at rest
- Speech clear; no respiratory distress observed
- Sustained upgaze → increased R ptosis; improves after rest
- Pupils equal/reactive; reflexes and sensation normal
- Limb power initially full; repeated shoulder abduction increasingly difficult
Investigations and treatment
- FBC, electrolytes, TSH (04/11): reported normal by laboratory
- No antibody testing, neurophysiology or imaging performed
- No condition-specific treatment started
Plan
- Patient concerned symptoms will affect employment
- Refer for assessment of possible myasthenia gravis; diagnosis unconfirmed; request investigation/management advice
- Complained receptionist was unfriendly during booking
- Earlier advice recorded: new swallowing/breathing problems → urgent medical assessment; severe difficulties → ambulance. GP addendum 06/11/2026: earlier escalation advice superseded; patient re-contacted and advised new swallowing difficulty → urgent medical assessment; any breathing difficulty or severe swallowing difficulty → call 000 immediately for ambulance; do not wait for breathing symptoms to become severe or for specialist appointment
Who is reading, and what do they need?
Dr Annie Deeley is the neuromuscular specialist receiving Ms Kori Hagan, born 14 March 1992, following her first neurology referral at the 6 November 2026 review. She needs the presentation and findings to assess an unconfirmed diagnosis. Absence of previous neurological or thyroid disease, regular medicines and known drug allergies provides optional context. Specialist terminology and concise grouped negatives suit this reader.
What to include
Selection is the skill the Content and Conciseness criteria reward. These notes earn their place:
| Case note | Why it belongs |
|---|---|
| Possible myasthenia gravis; diagnosis unconfirmed; specialist assessment and investigation/management advice requested. | Defines Dr Deeley's task without prejudging her assessment or implying that diagnostic confirmation has already occurred. |
| Gradual onset six weeks ago: intermittent right ptosis and binocular diplopia. | Establishes the presenting ocular symptoms and duration underlying this referral. |
| Worse with prolonged activity/late afternoon; improves after rest; often absent on waking. | The fluctuation pattern explains the clinical suspicion and why a single examination may not capture the presentation. |
| No dysphagia, choking, speech change or breathlessness. | Communicates the current absence of all four listed bulbar and respiratory symptoms relevant to assessment urgency. |
| Sustained upgaze increases right ptosis; improvement after rest. | Provides an observed, reproducible finding supporting specialist investigation rather than relying solely on reported symptoms. |
| Initially full limb power; repeated shoulder abduction increasingly difficult. | Adds objective limb fatigability, usefully complementing the ocular findings; omission remains defensible if those findings sufficiently support assessment. |
| Voluntarily stopped driving because of intermittent double vision. | Conveys a practical consequence of diplopia and an existing safety precaution without implying a formal driving restriction. |
| GP addendum 6 November: patient re-contacted with replacement advice—urgent assessment for new swallowing difficulty; immediate 000 ambulance call for any breathing difficulty or severe swallowing difficulty; do not wait for breathing symptoms to become severe or for the appointment. | Hands over the revised advice actually documented in this fictional case and makes clear that it supersedes the earlier escalation entry. |
What to leave out or compress
| Case note | Why it goes |
|---|---|
| Lives with partner; independent in daily activities. | Neither living arrangements nor general independence changes the requested diagnostic assessment; specific functional limitations are more informative. |
| Enjoys baking; entered local cake competition. | The hobby and competition provide no documented symptom or management information for Dr Deeley. |
| Sister's marriage difficulties; confidentiality requested. | This confidential third-party information has no stated connection to the neurological referral. |
| Appendicectomy at 15; uncomplicated recovery. | Despite appearing under medical history, this remote resolved operation does not advance the current neuromuscular assessment. |
| Complaint about receptionist's manner during booking. | The service complaint requires separate handling and does not help the specialist assess symptoms or plan investigations. |
| No recent infection; no weight loss. | These supplementary negatives may be omitted or briefly grouped when space is needed for the fluctuation pattern and examination. |
A paragraph plan for this case
Open with the assessment and advice request for an unconfirmed diagnosis, keeping identification brief, then establish the six-week ocular presentation and its activity, afternoon and rest pattern. Develop the examination findings and absence of dysphagia, choking, speech change or breathlessness; optional supporting details include hair-washing fatigue relieved by rest, selected negatives concerning persistent limb weakness, falls or neck weakness, absence of headache, eye pain, sensory disturbance or sphincter symptoms, the alert and comfortable resting appearance, clear speech, no observed respiratory distress, equal reactive pupils, normal reflexes and sensation, and laboratory-reported normal FBC, electrolytes and TSH on 4 November. Close with the investigation and management advice sought, the replacement escalation advice communicated in the dated GP addendum and driving cessation; if useful, briefly locate the absence of antibody testing, neurophysiology, imaging and condition-specific treatment before this close, with school-administration computer difficulties and employment concerns as optional functional context.
Where candidates slip on this task
- Interpret six weeks as symptom duration, not six months, and retain the fluctuating course rather than inventing progressive neurological deterioration from the separate report of increasingly difficult afternoon computer work.
- Distinguish voluntary driving cessation because of diplopia from a formal restriction or licence decision; do not invent advice already given, and treat hair-washing fatigue as rest-responsive rather than persistent weakness.
- Keep laboratory-reported normal results and normal examination components at their documented strength; neither normal pupils, reflexes and sensation nor the absence of observed respiratory distress establishes diagnostic exclusion or future safety.
- Use the dated GP addendum as the current escalation advice. Do not repeat the superseded severity threshold as current advice or suggest waiting for breathing difficulty to become severe before calling 000.
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
Must every supporting negative and investigation detail appear?
No. Prioritise the referral request, six-week ocular symptoms, fluctuation pattern, upgaze finding, all four listed bulbar/respiratory negatives and revised escalation advice. Other findings, normal laboratory results and absent specialist investigations can add context, but individually may be omitted when Dr Deeley can still understand and act on the referral. For n15, selecting only the absence of persistent limb weakness is reasonable; falls and neck weakness need not also be included.
How should the recorded escalation advice be handled?
Use the GP addendum dated 6 November, which explicitly supersedes the earlier entry and records that the patient was re-contacted. Communicate urgent assessment for new swallowing difficulty and an immediate 000 ambulance call for any breathing difficulty or severe swallowing difficulty. Breathing difficulty must not be allowed to worsen before seeking emergency help, and the patient should not wait for the specialist appointment. The model letter's account of replacement counselling comes from this fictional addendum, not from additional advice inferred from a teaching source. See Healthdirect guidance and NHS emergency treatment guidance, checked 6 November 2026.
Sources
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