Download writing - Monash University

WRITING IN MEDICINE (Language and Learning Online)
Writing in Medicine
These resources are intended to help you develop skills to improve your writing in Medicine, Nursing, and
Health Sciences subjects. Choose from modules on writing case reports in health sciences
<www.monash.edu.au/lls/llonline/lls/llonline/writing/medicine/health-sciences/index.xml> , reflective
writing <www.monash.edu.au/lls/llonline/lls/llonline/writing/medicine/reflective/index.xml> or writing in
Psychological Medicine
<www.monash.edu.au/lls/llonline/lls/llonline/writing/medicine/psychology/index.xml> . Regardless of
whether you are training to become a doctor, nurse, or other health practitioner, the ability to write clearly
is important in both your studies and your future careers.
Health Sciences case report
This tutorial contains information about writing case reports in health and
biomedical sciences, but you will also find much of the information useful for your
other Health Sciences subjects.
Annabelle is an undergraduate student in Health Sciences. First, take a look at
Annabelle's sample case report
<www.monash.edu.au/lls/llonline/writing/medicine/health-sciences/1.xml> . Ask
yourself whether the case report could be improved in any way. Next, read
Annabelle's annotated assignment
<www.monash.edu.au/lls/llonline/writing/medicine/health-sciences/2.xml> with
comments from her lecturer. Finally, you can read additional comments
<www.monash.edu.au/lls/llonline/writing/medicine/health-sciences/3.xml> on Annabelle's case report.
Annabelle's sample assignment
Introduction
What is a thyroid gland? How much do people understand about it? The organ is located at the base of
the neck, surrounding the trachea. This seemingly insignificant body part plays a vital role in maintaining
optimal development and ensuring the balance of an organism's central nervous system. In cases where
it malfunctions, endocrine diseases may arise. This is reflected in Erica* who is a sufferer of grave's
disease. This essay will first examine the effects of Erica's medical condition on her physical and
psychological health and on her lifestyle. Secondly, Erica's personal perception of the disease and
reaction to the diagnosis will be discussed. Next, environmental triggers and any other predictors that
may have an impact on aspects of the disease will be addressed. Finally, emphasis will be given to
Erica's expectations for the future. The author's own predictions will also be included strategically
throughout the essay.
Basic information
Born and raised in Australia, Erica's parents were originally Vietnamese refugees who fled to Australia
during the Vietnam War. At age 28, Erica is a female who holds the position of a sales and marketing
manager. Erica is currently married and lives with her husband.
Grave's disease and the parameters in the prediction of its occurrence
Ando, Latif and Davies (2004) define Grave's disease as a prevalent autoimmune disorder resulting from
the excess production of thyroid hormones. Hanna and Lafranchi (2002) suggest that this can be the
effect of complicated interactions between external and internal factors. An example of this was that while
Erica inherited the gene that caused Grave's disease from her mother, environmental stimulations such
as a bacteria infection, stress or simply geographic variables such as her Asian background might have
activated the onset of the disease. According to Erica, Asians are more prone to iodine-related diseases
due to their low iodine diet.
Erica was first diagnosed with a thyroid condition at the tender age of 21. Hanna and Lafranchi (2002)
contends that females are five times more likely to experience hyperthyroidism as compared to males and
that in the initial stage of the disease, symptoms are covert despite it having fatal consequences later on.
Statistically approximately 0.4% of adults suffer from Grave's disease. The severity of Erica's illness and
persistent sanctioning from her parents prompted her to seek medical help immediately. After having had
her blood test taken, antithyroid drugs were administered by the doctor based on the laboratory results.
This was indicative of the amount of radioactive iodine that is absorbed by the thyroid gland. A high iodine
uptake translates to Grave's disease (Isaacs and Ruggieri, 2004).
Various forms of treatment for thyroid disorders
There are three types of treatment for hyperthyroidism. They are antithyroid drugs (ATD), radioactive
therapy (RAI) and surgery with the first type of treatment being the most common and the last being rare
(Isaacs and Ruggieri, 2004).
Cooper (2005) explains that the use of such immunosuppressive drugs have an advantage over other
more dangerous measures such as radiation therapy and surgery. This is largely because oral medication
is more affordable and perceived as less life threatening. However, it is unknown to many that RAI can
also be administered in medication form- as a radioactive pill ingested orally (Hanna and Lafranchi,
2002). Besides, surveys comparing the effectiveness of the three main treatments of hyperthyroidism
have demonstrated up to 90% success rate for each. However, this form of treatment is more time
consuming and requires long-term commitment in that frequent tests on the thyroid needs to be done at
least once every month until the amount of thyroid hormones secreted appear to be of an acceptable
level. If this data remains consistent for the next three months, the amount of drug administered could be
lowered and eventually ceased within the span of 18 months (Cooper, 2005). According to Erica, her
doctor had to monitor the development of her thyroid. This means that she was required to undergo blood
tests on a monthly basis. Understandably, it was tricky to know the exact amount of medication to
prescribe since her condition varied periodically, without adhering to a specific trend. Cooper (2005)
asserts that an overdose may lead to hypothyroidism while insufficient administration will result in
uncontrolled levels of hyperthyroidism. Personally, Erica felt that visits to the practitioner posed as an
inconvenience because of her busy schedule at university. The late consultation hours added to her
reluctance to seek treatment regularly. In other words, Erica felt that obligations to visit the physician
frequently were an interference with her vocational and physical preoccupations (Jones, 2003).
Dilemma over the types of treatment to undertake
Erica's mom who was also a sufferer of Grave's disease could empathize with Erica's suffering perfectly.
She advised Erica to undergo either RAI or surgery, as they are the permanent means of solving her
thyroid problem. Monetary issues were not a problem for Erica, an Australian citizen who would be
covered by the government's public health insurance policy completely. However, the fear of adverse
effects from those treatments deterred Erica. In her view, the risks involved in them far outweighed the
positive outcomes they could have attained given the bleakness of the situation at that point in time.
Erica's primary concern was the effects of RAI on her fertility. However, her doctor assured her that this
threat was minimized since the pill was focused solely on the thyroid gland and not on the consumer's
reproductive organs. Erica's insecurities were not without reasons. Pauwels et al. (2000) hypothesized
the link between RAI and cancer, although only to a small extent. This was illustrated by the research that
points to increasing rate of cancer of the thyroid, stomach and other organs associated with digestion and
excretion. Furthermore, in RAI, killing more of the thyroid gland than necessary may result in permanent
hypothyroidism (Cooper, 2005). However, it was later acknowledged that the improvements brought
about by RAI far surpassed its disadvantages. This view was challenged by Isaacs and Ruggieri (2004)
who argued that the processes of RAI posed no threats of cancer.
Some experts have attested to the effectiveness of surgical methods of treatment but Isaacs and Ruggieri
(2004) refuted this belief. Instead, they claimed that any undestroyed thyroid tissue might redevelop after
the operation, causing another bout of hormonal attack on the victim. Hanna and Lafranchi (2002) further
highlighted that almost half of the patients who had surgery became hyperthyroid; another 1.2 % reported
to have lost their ability to speak and a small percentage of patients died as a result. Indeed, this verified
how crucial it was to involve a veteran endocrine specialist in carrying out the thyroid removal surgery as
any minor mistakes could result in irreversible damage to the patient's health or even death.
Environmental triggers
Even though iodine was alleged to reduce the adverse effects of hyperthyroidism, Erica did not intently
increase her iodine intake, believing that it was too insignificant a source to be considered important. Her
opinions were seconded by McLachlan (2005) who attested that iodine levels had no effects on the
amount of thyroid hormone produced by the body. On the contrary, studies conducted by Cooper (2003)
and Goodman (1994) underlined a correlation between iodine levels in the body and the occurrence of
hyperthyroidism. An illustration was made when comparing the iodine intake of citizens of Iceland
(normal) with that of Denmark (low) where the latter reported up to about 38% higher rates of the
population infected with Grave's disease. Apart from this, stress, steroids and other poor lifestyle habits
like smoking may also contribute to the development of Grave's disease, especially for those who may
have genetic predispositions (Cooper, 2003; Cooper, 2005).
Physical impacts of the disease
Cooper (2003) and Isaacs and Ruggieri (2004) proposes that hormonal imbalances often result in
patients experiencing heart palpitations. Physical manifestations of an over-worked heart and body
include continuous perspiration although inactive, intolerance to even low degrees of heat, irregular
pumping of the heart, breathlessness, trembling hands and in the worst scenario, death from a blocked
artery in the heart. Erica reported experiencing similar physical symptoms, which were mild on some days
but horrible on most occasions. For example, on certain days, she would not be able to muster the
strength to walk up a mere flight of stairs because she had been exceedingly exhausted from her body's
uncontrolled exertions. Hanna and Lafranchi (2002) and Cooper (2003) support the symptoms, explaining
that this may be due to extreme weakness that results in temporal loss of muscular control or numbness.
As a consequence, hyperthyroidism is often masked in clinical diagnosis and confused with
hypothyroidism where lethargy is a common feature.
Erica claimed that her thyroid hormone level was four to five times more active as compared to a healthy
individual, causing her thyroid gland to become tender and swollen. This was noted in Isaacs and
Ruggieri (2004) and Hanna and Lafranchi (2002) who attribute the trait to an over stimulation of the
thyroid gland. Subsequently, Erica commented that her eyes began to bulge, as experienced by 20-40%
of patients suffering from Grave's disease (Hanna and Lafranchi, 2002). Eye abnormalities can result
from the shortening of the muscles in the upper eyelids (Chang, Bernardino and Rubin, 2004; Hanna and
Lafranchi, 2002; Isaacs and Ruggieri, 2004). Erica also lost hefty clumps of hair. Isaacs and Ruggieri
(2004) identify similar problems in an individual suffering from the disease. The hair becomes thinner,
drops easily and may even turn gray.
Psychological impacts of the disease
Neural alterations such as low concentration span and changed personality is being observed in
individuals who suffer from this disease (Copper, 2003; Hanna and Lafranchi, 2002). Erica was under
such great psychological strain that her state of mind became unstable. For instance, Erica often
experienced outbursts and could not seem to control her emotions. Moreover, Erica admitted to
experiencing several periods of depression following her diagnosis. Isaacs and Ruggieri (2004) maintain
that hormonal stimulation of the brain is responsible for depressive and irritable moods. In addition,
Erica's irritability could be attributed to factors such as the effects of hormones that influenced her ability
to concentrate and the intense frustrations initiated by the distortions to her physical appearance. To
worsen the situation, Erica claimed that the condition disrupted her normal sleeping patterns (Hanna and
Lafranchi, 2002; Cooper, 2003). Despite this, Erica refused to submit to the use of sleeping pills in order
to fall asleep, as she strongly believed in natural sleep instead of an artificially induced one. In Erica's
opinion, society would not approve the use of sleeping tablets as a solution to insomnia in the long term.
Clearly, side effects, the fear of social stigmatism and the fear of dependency on the drug served as
reinforcements to prevent her from using sleeping pills. Erica's resistance to the use of those medications
was in fact a wise decision. Pagel and Parnes (2001) establishes that ingesting tranquilizing pills to
overcome chronic sleep disorders may adversely affect rapid eye movement (REM) sleep.
Behavioural changes in response to the disease
A significant change was determined in Erica whose appetite increased greatly. High levels of thyroid in
the bloodstream raised Erica's metabolic rate drastically (Goodman, 1994). For example, Erica could
consume a ten course Chinese banquet and still feel unsatisfied. In spite of her large food intake, Erica's
body was unable to absorb the vast amount of nutrients from these foods. Instead, most of it was lost in
diarrhoea (Hanna and Lafranchi, 2002). Hence, frequent trips to the toilet after a meal was inevitable.
More importantly, the loss of bodily fluids and nutrients drained Erica excessively, causing feelings of
lethargic. At these times, Erica would appear withdrawn and disinterested in her surroundings. At other
times, Erica tended to be tense, spoke rapidly, was restless and always fidgety. This was typically seen in
hyperthyroid individuals who alternate between mania and exhaustion (Goodman, 1994; Isaacs and
Ruggieri, 2004).
Attempts to revive any lost nutrients through vitamin supplements were futile given that it was excreted
from the digestive system almost instantly (Isaacs and Ruggieri, 2004). This had an effect on Erica's
outward appearance. She appeared disheveled and spindly as her metabolic mechanisms expended
calories more rapid than could be replaced in the diet. This implies that the Erica's body stores was
deficient in essential vitamins and minerals which include calcium and vitamin D. Since these compounds
are the precursor for healthy bone formation, Erica was warned of the possibility of developing
osteoporosis if her condition was left untreated for prolonged periods (Cooper, 2003; Whitney and Rolfes,
2005). Luckily, the onset of her disease occurred following her puberty years and hence her growth was
not stunted as seen in cases of children who developed Grave's disease before maturity and thus failed
to attain the full grown stature of an adult (Goodman, 1994; Hanna and Lafranchi, 2002).
Cognitive responses to the disease
Despite imposing the sick role on Erica, her parents' advice for her to remain indoors and eat a greater
amount of nutritious foods was ignored. Erica rebelled against their instructions. Although Erica was intent
on improving her condition, she was not prepared to sacrifice her social life. Being young and hotblooded, she was eager to explore the world and refused to be restricted by the physical constraints of
her illness. Looking back, she had naively thought that the problem was temporal and that the symptoms
would disappear within a matter of months or even weeks. Moreover, Erica believed that there was no
connection between her level of physical activity and the status of her disease.
Erica's optimistic appraisal of the situation prompted her to adopt effective ways of dealing with the
personal crisis (Jones, 2003). Gradually, as Erica approached the 'acceptance stage', she began to see
the 'funny side' of the disease and learnt to overlook the negative impacts. Unlike most girls who had to
constantly watch their diet to stay slim, Erica had the freedom of eating whatever she fancied without
worrying about obesity. Erica could eat four to five times more than most people. For instance, she
consumes three times more than her husband in daily meals. Obviously, this feeling of blessing can only
be achieved by disregarding the fact that her body was absorbing nil amounts of nutrients and could even
be losing lean tissues in the form of muscles needed to keep the body fit (Isaacs and Ruggieri, 2004). An
extra bonus lay in the surplus supply of energy Erica experienced continually. This enabled her to be
more productive and proficient as compared to her peers. The conscious choice of adopting a positive
attitude instead of dwelling in an eternal mode of self- pity promoted improvements in both her physical
and mental strength. Likewise, Jones (2003) contends a link between optimism and good health.
ways to manage the disease with her mum soothed her frustrations considerably. Above all, Erica argues
that it was her strong religious faith and close-knit church community, which carried her through the most
challenging period of her life.
Side effects of antithyroid drugs
After consulting several reliable sources, she decided to undergo radioidodine therapy. This was largely
because while antithyroid drugs could suppress the symptoms of her illness, it could not stem the
problem of nutrient loss such as calcium from her body (Isaac and Ruggieri, 2004). This step of faith
arrived only after seven years of antithyroid drug treatment. For almost a decade, Erica had had to put up
with the discomforts and side effects brought about by the use of antithyroid drugs. Negative effects from
the incorporation of thyroid medication range from those that are benign-rashes and other allergic
reactions to those with malignant effects-liver failure and even death (Cooper, 2005). Fortunately, Erica
noticed only mild symptoms. They were rapid weight gain, weariness and slow hand-eye coordination.
Hanna and Lafranchi (2002) and Isaacs and Ruggieri (2004) recognize the necessity to decrease the
amount of food use during treatment because while the drug returns the body's metabolic rate to its
normal level, the individual's appetite remain heightened and may result in weight gain. She also
experienced irregular menstrual cycles for a few years (Hanna and Lafranchi, 2002). This could be
ascribed to the abnormal amount of estrogen and progesterone that were circulated around the body at
the initial stage of the disease as well as the sudden hormonal imbalance caused by the drugs (Cooper,
2003; Hanna and Lafranchi, 2002; Isaacs and Ruggieri, 2004).
Future expectations
Having started on the new form of treatment- RAI, Erica has observed marked improvements in her
condition. Erica expects full recovery in the near future after which she and her husband hope to start a
family.
Conclusion
Conceivably, Erica portrays herself as an independent and resilient individual who has learnt to cope and
manage her illness with the support and counseling of her family and friends. At present, scarce
information is available regarding the underlying mechanisms for the symptoms of the disease. Even
though possible suggestions and speculations have been quoted, their inconsistency makes it difficult to
discern between myths and the absolute truth. No one knows what the future will bring in terms of
developments in treating thyroid disorders, much less the fate of Erica. However, with modern science
and technology, a new invention or therapy for eliminating endocrine diseases could well be underway.
References
Ando, T, Latif, R and Davies, TF 2004, 'Concentration-dependent regulation of thyrotropin receptor
function by thyroid-stimulating antibody', Journal of Clinical Investigation, vol. 113, no. 11, pp. 1589-1595.
Cooper, DS 2003, 'Hyperthyroidism', The Lancet London, vol. 362, no. 9382, pp. 459.
Cooper, DS 2005, 'Antithyroid drugs', The New England Journal of Medicine, vol. 352, no. 9, pp. 905-914.
Eli, LC, Bernardino, CR and Rubin, PAD 2004, 'Normalization of upper eyelid height and contour after
bony decompression in thyroid-related ophthalmopathy: A digital image analysis', Archives of
Ophthalmology, vol. 122, no. 12, pp. 1882-1885.
Goodman, HM 1994, Basic Medical Endocrinology, 2nd edn, Raven press, New York.
Hanna, CE and Lafranchi, SH 2002, 'Adolescent thyroid disorders', Adolescent Medicine, vol. 13, no. 1,
pp. 13-36.
Isaacs, S and Ruggieri, P 2004, A simple guide to thyroid disorders: From treatment to diagnosis,
Addicus Books, Nebraska.
Jones, K 2003, Health and human behaviour, Bookpac Production Services, Singapore.
McLachlan, SM, Braley-Mullen, H, Chen, C, Aliesky, H, Pichurin, PN and Rapoport, B 2005, ' Dissociation
between iodide-induced thyroiditis and antibody-mediated hyperthyroidism in NOD.H-2h4 Mice',
Endocrinology, vol. 146, no.1, pp.294.
Pagel, JF and Parnes, BL 2001, 'Medications for the treatment of sleep disorders: An overview', Pubmed,
vol. 3, no. 3, pp.118-125.
Pauwels, EKJ, Smit, JWA, Slats, A, Bourguignon, M and Overbeek, F 2000, 'Health effects of therapeutic
use of (131)I in hyperthyroidism', The Quarterly Journal of Nuclear Medicine, vol. 44, no. 4, pp. 333-339.
Whitney, E and Rolfes, SR 2005, Understanding Nutrition, Peter Marshall, United States of America.
Annabelle's assignment and what her lecturer thought
Click on the highlighted text to see the comments.
Introduction
[1]What
is a thyroid gland? How much do people understand about it? The organ is located at the base of
the neck, surrounding the trachea. This seemingly insignificant body part plays a vital role in maintaining
optimal development and ensuring the balance of an organism's central nervous system. In cases where
it malfunctions, endocrine diseases may arise. This is reflected in Erica* who is a sufferer of grave's
disease. This essay will first examine the effects of Erica's medical condition on her physical and
psychological health and on her lifestyle. Secondly, Erica's personal perception of the disease and
reaction to the diagnosis will be discussed. Next, environmental triggers and any other predictors that
may have an impact on aspects of the disease will be addressed. [2]Finally, emphasis will be given to
Erica's expectations for the future. The author's own predictions will also be included strategically
throughout the essay.
Basic information
Born and raised in Australia, Erica's parents were originally Vietnamese refugees who fled to Australia
during the Vietnam War. [3]At age 28, Erica is a female who holds the position of a sales and marketing
manager. Erica is currently married and lives with her husband.
Grave's disease and the parameters in the prediction of its occurrence
Ando, Latif and Davies (2004) define Grave's disease as a prevalent autoimmune disorder resulting from
the excess production of thyroid hormones. Hanna and Lafranchi (2002) suggest that this can be the
effect of complicated interactions between external and internal factors. An example of this was that while
Erica inherited the gene that caused Grave's disease from her mother, environmental stimulations such
as a bacteria infection, stress or simply geographic variables such as her Asian background might have
activated the onset of the disease. According to Erica, Asians are more prone to iodine-related diseases
due to their low iodine diet.
Erica was first diagnosed with a thyroid condition at the tender age of 21. [4]Hanna and Lafranchi (2002)
contends that females are five times more likely to experience hyperthyroidism as compared to males and
that in the initial stage of the disease, symptoms are covert despite it having fatal consequences later on.
Statistically approximately 0.4% of adults suffer from Grave's disease. The severity of Erica's illness and
persistent sanctioning from her parents prompted her to seek medical help immediately. After having had
her blood test taken, antithyroid drugs were administered by the doctor based on the laboratory results.
[5]This was indicative of the amount of radioactive iodine that is absorbed by the thyroid gland. A high
iodine uptake translates to Grave's disease (Isaacs and Ruggieri, 2004).
Various forms of treatment for thyroid disorders
There are three types of treatment for hyperthyroidism. [6]They are antithyroid drugs (ATD), radioactive
therapy (RAI) and surgery with the first type of treatment being the most common and the last being rare
(Isaacs and Ruggieri, 2004).
Cooper (2005) explains that the use of such immunosuppressive drugs have an advantage over other
more dangerous measures such as radiation therapy and surgery. This is largely because oral medication
is more affordable and perceived as less life threatening. However, it is unknown to many that RAI can
also be administered in medication form- as a radioactive pill ingested orally (Hanna and Lafranchi,
2002). Besides, surveys comparing the effectiveness of the three main treatments of hyperthyroidism
have demonstrated up to 90% success rate for each. However, [7]this form of treatment is more time
consuming and requires long-term commitment in that frequent tests on the thyroid needs to be done at
least once every month until the amount of thyroid hormones secreted appear to be of an acceptable
level. If this data remains consistent for the next three months, the amount of drug administered could be
lowered and eventually ceased within the span of 18 months (Cooper, 2005). According to Erica, her
doctor had to monitor the development of her thyroid. This means that she was required to undergo blood
tests on a monthly basis. Understandably, it was tricky to know the exact amount of medication to
prescribe since her condition varied periodically, without adhering to a specific trend. Cooper (2005)
asserts that an overdose may lead to hypothyroidism while insufficient administration will result in
uncontrolled levels of hyperthyroidism. Personally, Erica felt that visits to the practitioner [8]posed as an
inconvenience because of her busy schedule at university. The late consultation hours added to her
reluctance to seek treatment regularly. [9]In other words, Erica felt that obligations to visit the physician
frequently were an interference with her vocational and physical preoccupations (Jones, 2003).
Dilemma over the types of treatment to undertake
Erica's mom who was also a sufferer of Grave's disease could empathize with Erica's suffering perfectly.
She advised Erica to undergo either RAI or surgery, as they are the permanent means of solving her
thyroid problem. Monetary issues were not a problem for Erica, an Australian citizen who would be
covered by the government's public health insurance policy completely. However, the fear of adverse
effects from those treatments deterred Erica. In her view, the risks involved in them far outweighed the
positive outcomes they could have attained given the bleakness of the situation at that point in time.
Erica's primary concern was the effects of RAI on her fertility. However, her doctor assured her that this
threat was minimized since the pill was focused solely on the thyroid gland and not on the consumer's
reproductive organs. [10]Erica's insecurities were not without reasons. Pauwels et al. (2000) hypothesized
[11]the link between RAI and cancer, although only to a small extent. This was illustrated by the research
that points to increasing rate of cancer of the thyroid, stomach and other organs associated with digestion
and excretion. Furthermore, in RAI, killing more of the thyroid gland than necessary may result in
permanent hypothyroidism (Cooper, 2005). However, it was later acknowledged that the improvements
brought about by RAI far surpassed its disadvantages. [12]This view was challenged by Isaacs and
Ruggieri (2004) [13]who argued that the processes of RAI posed no threats of cancer.
Some experts have attested to the effectiveness of surgical methods of treatment but Isaacs and Ruggieri
(2004) refuted this belief. Instead, they claimed that any undestroyed thyroid tissue might redevelop after
the operation, causing another bout of hormonal attack on the victim. Hanna and Lafranchi (2002) further
highlighted that almost half of the patients who had surgery became hyperthyroid; another 1.2 % reported
to have lost their ability to speak and a small percentage of patients died as a result. [14]Indeed, this
verified how crucial it was to involve a veteran endocrine specialist in carrying out the thyroid removal
surgery as any minor mistakes could result in irreversible damage to the patient's health or even death.
Environmental triggers
Even though iodine was alleged to reduce the adverse effects of hyperthyroidism, Erica did not [15]intently
increase her iodine intake, believing that it was too insignificant a source to be considered important.
[16]Her opinions were seconded by McLachlan (2005) who attested that iodine levels had no effects on the
amount of thyroid hormone produced by the body. On the contrary, studies conducted by Cooper (2003)
and Goodman (1994) underlined a correlation between iodine levels in the body and the occurrence of
hyperthyroidism. An illustration was made when comparing the iodine intake of citizens of Iceland
(normal) with that of Denmark (low) where the latter reported up to about 38% higher rates of the
population infected with Grave's disease. Apart from this, stress, steroids and other poor lifestyle habits
like smoking may also contribute to the development of Grave's disease, especially for those who may
have genetic predispositions (Cooper, 2003; Cooper, 2005).
Physical impacts of the disease
Cooper (2003) and Isaacs and Ruggieri (2004) [17]proposes that hormonal imbalances often result in
patients experiencing heart palpitations. Physical manifestations of an over-worked heart and body
include continuous perspiration although inactive, intolerance to even low degrees of heat, irregular
pumping of the heart, breathlessness, trembling hands and in the worst scenario, death from a blocked
artery in the heart. Erica reported experiencing similar physical symptoms, which were mild on some days
but horrible on most occasions. For example, on certain days, she would not be able to muster the
strength to walk up a mere flight of stairs because she had been [18]exceedingly exhausted from her
body's uncontrolled exertions. Hanna and Lafranchi (2002) and Cooper (2003) support the symptoms,
explaining that this may be due to extreme weakness that results in temporal loss of muscular control or
numbness. As a consequence, hyperthyroidism is often masked in clinical diagnosis and confused with
hypothyroidism where lethargy is a common feature.
Erica claimed that her thyroid hormone level was four to five times more active as compared to a healthy
individual, causing her thyroid gland to become tender and swollen. This was noted in Isaacs and
Ruggieri (2004) and Hanna and Lafranchi (2002) who attribute the trait to an over stimulation of the
thyroid gland. Subsequently, Erica commented that her eyes began to bulge, as experienced by 20-40%
of patients suffering from Grave's disease (Hanna and Lafranchi, 2002). Eye abnormalities can result
from the shortening of the muscles in the upper eyelids (Chang, Bernardino and Rubin, 2004; Hanna and
Lafranchi, 2002; Isaacs and Ruggieri, 2004). Erica also lost hefty clumps of hair. Isaacs and Ruggieri
(2004) identify similar problems in an individual suffering from the disease. The hair becomes thinner,
drops easily and may even turn gray.
[20]Psychological
impacts of the disease
Neural alterations such as low concentration span and changed personality [19]is being observed in
individuals who suffer from this disease (Copper, 2003; Hanna and Lafranchi, 2002). Erica was under
such great psychological strain that her state of mind became unstable. For instance, Erica often
experienced outbursts and could not seem to control her emotions. Moreover, Erica admitted to
experiencing several periods of depression following her diagnosis. Isaacs and Ruggieri (2004) maintain
that hormonal stimulation of the brain is responsible for depressive and irritable moods. In addition,
Erica's irritability could be attributed to factors such as the effects of hormones that influenced her ability
to concentrate and the intense frustrations initiated by the distortions to her physical appearance. To
worsen the situation, Erica claimed that the condition disrupted her normal sleeping patterns (Hanna and
Lafranchi, 2002; Cooper, 2003). Despite this, Erica refused to submit to the use of sleeping pills in order
to fall asleep, as she strongly believed in natural sleep instead of an artificially induced one. In Erica's
opinion, society would not approve the use of sleeping tablets as a solution to insomnia in the long term.
Clearly, side effects, the fear of social stigmatism and the fear of dependency on the drug served as
reinforcements to prevent her from using sleeping pills. Erica's resistance to the use of those medications
was in fact a wise decision. Pagel and Parnes (2001) establishes that ingesting tranquilizing pills to
overcome chronic sleep disorders may adversely affect rapid eye movement (REM) sleep.
Behavioural changes in response to the disease
A significant change was determined in Erica whose appetite increased greatly. High levels of thyroid
hormone in the bloodstream raised Erica's metabolic rate drastically (Goodman, 1994). For example,
Erica could consume a ten course Chinese banquet and still feel unsatisfied. In spite of her large food
intake, Erica's body was unable to absorb the vast amount of nutrients from these foods. Instead, most of
it was lost in diarrhoea (Hanna and Lafranchi, 2002). Hence, frequent trips to the toilet after a meal was
inevitable. More importantly, the loss of bodily fluids and nutrients drained Erica excessively, causing
feelings of [21]lethargic. At these times, Erica would appear withdrawn and disinterested in her
surroundings. At other times, Erica tended to be tense, spoke rapidly, was restless and always fidgety.
This [22]was typically seen in hyperthyroid individuals who alternate between mania and exhaustion
(Goodman, 1994; Isaacs and Ruggieri, 2004).
Attempts to revive any lost nutrients through vitamin supplements were futile given that it was excreted
from the digestive system almost instantly (Isaacs and Ruggieri, 2004). This had an effect on Erica's
outward appearance. She appeared disheveled and spindly as her metabolic mechanisms expended
calories more rapidly than could be replaced in the diet. This implies that the Erica's body stores were
deficient in essential vitamins and minerals which include calcium and vitamin D. Since these compounds
are the precursor for healthy bone formation, Erica was warned of the possibility of developing
osteoporosis if her condition was left untreated for prolonged periods (Cooper, 2003; Whitney and Rolfes,
2005). [23]Luckily, the onset of her disease occurred following puberty years and hence her growth was
not stunted as seen in cases of children who developed Grave's disease before maturity and thus failed
to attain the full grown stature of an adult (Goodman, 1994; Hanna and Lafranchi, 2002).
Cognitive responses to the disease
Despite imposing the sick role on Erica, her parents' advice for her to remain indoors and eat a greater
amount of nutritious foods was ignored. Erica rebelled against their instructions. Although Erica was intent
on improving her condition, she was not prepared to sacrifice her social life. Being young and hotblooded, she was eager to explore the world and refused to be restricted by the physical constraints of
her illness. Looking back, she had naively thought that the problem was [24]temporal and that the
symptoms would disappear within a matter of months or even weeks. Moreover, Erica believed that there
was no connection between her level of physical activity and the status of her disease.
Erica's optimistic appraisal of the situation prompted her to adopt effective ways of dealing with the
personal crisis (Jones, 2003). Gradually, as Erica approached the 'acceptance stage', she began to see
the 'funny side' of the disease and learnt to overlook the negative impacts. Unlike most girls who had to
constantly watch their diet to stay slim, Erica had the freedom of eating whatever she fancied without
worrying about obesity. Erica could eat four to five times more than most people. For instance, she
consumes three times more than her husband in daily meals. Obviously, this feeling of blessing can only
be achieved by disregarding the fact that her body was absorbing nil amounts of nutrients and could even
be losing lean tissues in the form of muscles needed to keep the body fit (Isaacs and Ruggieri, 2004). An
extra bonus lay in the surplus supply of energy Erica experienced continually. This enabled her to be
more productive and proficient as compared to her peers. The conscious choice of adopting a positive
attitude instead of dwelling in an eternal mode of self- pity promoted improvements in both her physical
and mental strength. Likewise, Jones (2003) contends a link between optimism and good health.
Erica's assertiveness and uncompromising personality made her feel that the onus of finding out more
information to assist in her self-awareness of the disease was ultimately on her.Jones (2003)allenging
period of her life.
Side effects of antithyroid drugs
After consulting several reliable sources, [25]she decided to undergo radioidodine therapy. This was
largely because while antithyroid drugs could suppress the symptoms of her illness, it could not stem the
problem of nutrient loss such as calcium from her body (Isaac and Ruggieri, 2004). This step of faith
arrived only after seven years of antithyroid drug treatment. For almost a decade, Erica had had to put up
with the discomforts and side effects brought about by the use of antithyroid drugs. Negative effects from
the incorporation of thyroid medication range from those that are benign-rashes and other allergic
reactions to those with malignant effects-liver failure and even death (Cooper, 2005). Fortunately, Erica
noticed only mild symptoms. They were rapid weight gain, weariness and slow hand-eye coordination.
Hanna and Lafranchi (2002) and Isaacs and Ruggieri (2004) recognize the necessity to decrease the
amount of food use during treatment because while the drug returns the body's metabolic rate to its
normal level, the individual's appetite [26]remain heightened and may result in weight gain. She also
experienced irregular menstrual cycles for a few years (Hanna and Lafranchi, 2002). This could be
ascribed to the abnormal amount of estrogen and progesterone that circulated around the body at the
initial stage of the disease as well as the sudden hormonal imbalance caused by the drugs (Cooper,
2003; Hanna and Lafranchi, 2002; Isaacs and Ruggieri, 2004).
Future expectations
Having started on the new form of treatment- RAI, Erica has observed marked improvements in her
condition. [27]Erica expects full recovery in the near future after which she and her husband hope to start a
family.
[30]Conclusion
[28]Conceivably,
Erica portrays herself as an independent and resilient individual who has learnt to cope
and manage her illness with the support and counseling of her family and friends. At present, scarce
information is available regarding the underlying mechanisms for the symptoms of the disease. Even
though possible suggestions and speculations have been quoted, their inconsistency makes it difficult to
discern between [29]myths and the absolute truth. No one knows what the future will bring in terms of
developments in treating thyroid disorders, much less the fate of Erica. However, with modern science
and technology, a new invention or therapy for eliminating endocrine diseases could well be underway.
[31]References
Ando, T, Latif, R and Davies, TF 2004, 'Concentration-dependent regulation of thyrotropin receptor
function by thyroid-stimulating antibody', Journal of Clinical Investigation, vol. 113, no. 11, pp. 1589-1595.
Cooper, DS 2003, 'Hyperthyroidism', The Lancet London, vol. 362, no. 9382, pp. 459.
Cooper, DS 2005, 'Antithyroid drugs', The New England Journal of Medicine, vol. 352, no. 9, pp. 905-914.
Eli, LC, Bernardino, CR and Rubin, PAD 2004, 'Normalization of upper eyelid height and contour after
bony decompression in thyroid-related ophthalmopathy: A digital image analysis', Archives of
Ophthalmology, vol. 122, no. 12, pp. 1882-1885.
Goodman, HM 1994, Basic Medical Endocrinology, 2nd edn, Raven press, New York.
Hanna, CE and Lafranchi, SH 2002, 'Adolescent thyroid disorders', Adolescent Medicine, vol. 13, no. 1,
pp. 13-36.
Isaacs, S and Ruggieri, P 2004, A simple guide to thyroid disorders: From treatment to diagnosis,
Addicus Books, Nebraska.
Jones, K 2003, Health and human behaviour, Bookpac Production Services, Singapore.
McLachlan, SM, Braley-Mullen, H, Chen, C, Aliesky, H, Pichurin, PN and Rapoport, B 2005, ' Dissociation
between iodide-induced thyroiditis and antibody-mediated hyperthyroidism in NOD.H-2h4 Mice',
Endocrinology, vol. 146, no.1, pp.294.
Pagel, JF and Parnes, BL 2001, 'Medications for the treatment of sleep disorders: An overview', Pubmed,
vol. 3, no. 3, pp.118-125.
Pauwels, EKJ, Smit, JWA, Slats, A, Bourguignon, M and Overbeek, F 2000, 'Health effects of therapeutic
use of (131)I in hyperthyroidism', The Quarterly Journal of Nuclear Medicine, vol. 44, no. 4, pp. 333-339.
Whitney, E and Rolfes, SR 2005, Understanding Nutrition, Peter Marshall, United States of America.
[32]
[Lecturer's overall comments]
[1]
Comment
Starting your essay with rhetorical questions may be good for creating interest, but is not common in
medical and scientific writing. Another, perhaps more appropriate way of expressing this idea would be as
follows: The thyroid gland is a little-understood organ located at the base of the neck surrounding the
trachea.
[2]
Comment
This introduction provides a thorough and clearly expressed outline of the intended essay structure.
[3]
Comment
This could be expressed more simply. For example:
Erica is female, 28 years old, and works as a sales and marketing manager.
[4]
Comment
When referring to sources, it is important to maintain subject-verb agreement. In this case it should be
written as follows:
Hanna and Lafranchi (2002) contend that...
[5]
Comment
Note the range of sources referred to in outlining the medical details of the condition. Lecturers look to
see an adequate range of references. They also look to see how current the sources are. In this essay,
recent sources (2002, 2004) have been used. This is important to ensure that the information you provide
about current knowledge and treatment is up-to-date.
[6]
Comment
Be careful not to have too many very short paragraphs (eg. consisting of only one or two sentences). In
this essay the following three sentences could be combined to form the first paragraph of this section.
The second paragraph would start as follows:
Surveys comparing the effectiveness of the three main treatments of hyperthyroidism demonstrate up to
90% success rate for each.
[7]
Comment
Is it clear which form of treatment the word 'this' is referring to? Be careful with your use of referents (eg.
this, that) to ensure that the meaning is clear and unambiguous.
[8]
Comment
Although you could write 'posed a problem for her', this word is not used correctly in the text. Why not
simply write:
Erica found the visits to the practitioner inconvenient...
Remember that the object of good writing in the medical and scientific fields is to express concepts
simply, clearly and unambiguously.
[9]
Comment
Note that the student relates the medical information on the condition to Erica's specific case - there is
good integration of the theoretical information obtained from academic sources and the information
provided by the patient (in the interview).
[10]
Comment
Notice that the focus in this section is on the patient's perspective and concerns in terms of the choice of
treatment. This is consistent with the requirements of the task, which is to view the condition and
experience of illness through the patient's eyes.
[11]
Comment
When referring to something for the first time, the article 'a' or 'an' is usually used. Subsequent references
then use 'the'. In this case, this is the first reference in the text to a link between RAI and cancer, and
therefore 'a' is more correct. Although this may appear a minor error, it can often confuse the reader
momentarily, and in that way cause a break in concentration on the essay content.
[12]
Comment
In this sentence is it clear to which treatment, and to whose views, the words 'this view' refers? This
problem could be corrected by moving the sentence to directly after the 'view' in question - for example:
Pauwels et al. (2000) hypothesized a link between RAI and cancer. This was illustrated by the research
that points to an increasing rate of cancer of the thyroid, stomach and other organs associated with
digestion and excretion. However this view has been challenged by Isaacs and Ruggieri (2004), who
argue that the processes of RAI pose no threat of cancer.
Another way of correcting this problem would be to provide a brief summary of the 'view' within the
sentence. For example:
The view that RAI is linked to cancer has been challenged by Isaacs and Ruggieri (2004), who argue that
the process poses no such threat.
[13]
Comment
Note that present verb tense is more appropriate in these sentences, due to the currency of the work
being cited. Using reporting verbs in the present tense when appropriate gives your writing a greater
sense of currency, something valued by lecturers and expected in academic writing in the medical and
scientific fields.
[14]
Comment
If this finding continues to be relevant to current practice (as it does), then present tense would be more
appropriate. For example:
Indeed, this verifies how crucial it is to involve a veteran endocrine specialist...
[15]
Comment
It is unclear whether this word expresses the writer's idea correctly. Perhaps she meant to write
'intentionally'. In fact, neither word is necessary in the sentence. For example:
Erica did not increase her iodine intake...
When proofreading your essay, check for words and phrases that are not necessary (redundant).
Removing redundant language will make your ideas clearer to your reader, and also help you to avoid
exceeding the word count.
[16]
Comment
Given the citation is very current, in fact within the same year in which the essay was written, present verb
tense is more appropriate. For example:
H er opinions are seconded by McLachlan (2005), who attests that iodine levels have no effect on the
amount of thyroid hormone produced by the body.
[17]
Comment
Subject-verb agreement error.
[18]
Comment
Is the word 'exceedingly' necessary in this sentence?
[19]
Comment
When referring to an action occurring both in the past and up to the present, the present perfect tense
should be used. For example:
Neural alterations such as low concentration span and changed personality have been observed in
individuals...
[20]
Comment
The following is an example of a cohesive, well-structured paragraph with excellent integration of
theoretical and patient perspectives.
[21]
Comment
This is an error in word form. The adjective lethargic has been used instead of the noun lethargy. Note
that these errors may not be identified using a spellchecker (as the word is correctly spelt), but may using
a grammar check.
[22]
Comment
Verb tense.
[23]
Comment
In this section the writer displays a detailed knowledge of the patient's experiences of her condition. In
order to provide this level of detail, it is important to:




(i) develop a good rapport with the patient during the interview
(ii) show consideration and ask questions with sensitivity
(iii) ask follow-up questions to elicit more detailed responses
(iv) record patient answers in a clear and systematic way
[24]
Comment
This is a word choice error. The writer has written the word temporal but she means temporary. This error
will not show up through a grammar check, because there is no grammatical error. These are less serious
errors, however care needs to be taken because they may significantly change the meaning of a
sentence.
[25]
Comment
When starting a new section or paragraph it is preferable to use the patient's name rather than the
pronoun 'he' or 'she'. For example:
After consulting several reliable sources Erica decided to…
[26]
Comment
Subject-verb agreement. For example:
…the individual's appetite remains heightened…
[27]
Comment
Based on your research of the condition, you could comment on whether this appears a realistic
expectation.
[28]
Comment
Is the word conceivably correct here? What does it mean? Is it necessary? The sentence is clearer and
reads better without this word — it is redundant.
[29]
Comment
In relation to this topic, and in the biomedical and health sciences generally, we are not dealing with either
'myth' or 'absolute truth'. The idea contained in this sentence could be expressed more simply and clearly.
For example:
Even though suggestions and speculation regarding possible future treatments have been considered, no
new treatments are available at present.
[30]
Comment
The conclusion provides a concise summary of the main points of the essay, along with a brief comment
on possible future developments in the treatment of the condition. It should be consistent with the
introduction.
[31]
Comment
References are arranged alphabetically by author's surname, using the Harvard style. Note the range and
currency of references consulted. These include:



(i) general medical journals
(ii) specialist medical journals
(iii) textbooks
[32]
Overall Comments
This is a clear, well-structured and interesting essay. The introduction provides a thorough outline of the
intended essay structure and clearly addresses the requirements of the assignment task. Information is
organised in a clear and logical way, and this organization is made explicit by the use of headings.
Information of a general nature on the patient's condition is presented along with details of the patient's
specific experience of the condition. As such, theoretical information and personal information regarding
the patient are integrated. The medical information provided is generally relevant to the specific case, and
a range of recent sources have been referred to. With the exception of the first sections, coverage of the
various perspectives required in the assignment task is balanced, with the focus mostly on the patient's
experiences and beliefs regarding her condition. Specific details of the patient's experiences and attitude
are presented in a sensitive and non-judgmental manner.
The conclusion provides a concise summary of the main points of the essay, along with a brief comment
on possible future developments in the treatment of the condition. The reference list indicates that the
student consulted a range of sources, including general medical journals, specialist medical journals and
textbooks, with several of her sources published within the last two years.
Additional lecturer comments
Lecturer: Dr. Ken Jones
This paper has some significant strengths. The student has an excellent grasp of the literature, and has
used a well-selected set of resources. The assignment has been correctly interpreted and the important
issues have been discussed. It is also a well-structured essay, with an introduction that provides the
reader with a clear outline of the intended structure. However, as a case report this paper has a major
flaw.
The paper begins with a fairly detailed outline of the thyroid gland, including information on the
occurrence and treatment of thyroid conditions. The specific symptoms that lead to the diagnosis of
Erica's condition are not described until page 6. This is contrary to the guidelines for this assignment,
which urge students to start with the person and their individual experience. There is too little about Erica
in the early sections of this paper. Most sections up to page 7 begin with scientific information of a
general kind about thyroid disease, and then move on to Erica. Once Erica's situation is more fully
outlined it becomes clear that much of the general information previously provided on thyroid disease is
irrelevant or trivial. The focus of the paper should be the other way around: firstly, this is Erica, and
secondly, this is the relevant and important literature relating to her condition.
Basically, as a case report the paper gets better as it goes along. The focus shifts from thyroid disease in
a general sense to Erica - a person who has to live with thyroid disease. If the early sections of the report
had taken the same approach, the paper would have received a better mark.
Some imprecise and inaccurate use of terminology detracts from the quality of the paper. For example,
the following phrase from page 2: "environmental stimulations such as bacteria infection, stress or simply
geographic variables such as her Asian background might have activated the disease". The word 'stimuli'
should be used rather than stimulations and 'bacterial' rather than bacteria. Similarly in the phrase from
page 8 "the fear of social stigmatism and the fear of dependency" the word 'stigma' should be used rather
than stigmatism. Also, this student tends to use too many 'chatty' adjectives, which are not consistent with
an academic writing style. Some examples of these are:




"Erica was first diagnosed with a thyroid condition at the tender age of 21." (p. 2)
"Erica also lost hefty clumps of hair." (p. 7)
"Being young and hot-blooded, she was eager to explore the world..." (p. 10)
"The conscious choice of adopting a positive attitude instead of dwelling in an eternal mode of
self pity..." (p. 11)
It is important to be consistent in using acronyms (words formed from the first letters of a term to act as an
abbreviation). This student correctly provides an acronym for the term antithyroid drugs (ATD), but then
fails to consistently use this acronym, moving between the full term and acronym throughout the paper.
She uses the acronym RAI for the term radioactive therapy (p. 3), but this acronym actually refers to
'radioactive iodine'.
Another issue is the length of the paper. At around 3000 words the paper is overly long - careful editing to
avoid repetition and to remove some detail not directly relevant to Erica's condition would have improved
the paper and made it a more appropriate length.
In addition to careful editing, the importance of proofreading cannot be overemphasized. Careless errors
detract from the quality of a paper, and these should be picked up and corrected as part of the
proofreading process.
Reflective writing
Reflection on practice is an important aspect of your ongoing professional learning. This section explains
what is meant by reflective writing
<www.monash.edu.au/lls/llonline/writing/medicine/reflective/1.xml> and the term critical incident
<www.monash.edu.au/lls/llonline/writing/medicine/reflective/2.xml> , and helps you explore the reflective
learning process <www.monash.edu.au/lls/llonline/writing/medicine/reflective/3.xml> .
You are asked to write a critical incident report as part of your course. You will also find a format for the
critical incident report <www.monash.edu.au/lls/llonline/writing/medicine/reflective/4.xml> , a sample piece
of student writing <www.monash.edu.au/lls/llonline/writing/medicine/reflective/5.xml> , criteria for
assessment <www.monash.edu.au/lls/llonline/writing/medicine/reflective/6.xml> and suggestions to help
avoid some common errors in reflective writing
<www.monash.edu.au/lls/llonline/writing/medicine/reflective/7.xml> .
The section on characteristics of reflective writing
<www.monash.edu.au/lls/llonline/writing/medicine/reflective/8.xml> covers language features like



tenses <www.monash.edu.au/lls/llonline/writing/medicine/reflective/8.1.xml>
speculative and hypothetical writing
<www.monash.edu.au/lls/llonline/writing/medicine/reflective/8.2.xml>
the language of self-reflection vs criticism
<www.monash.edu.au/lls/llonline/writing/medicine/reflective/8.3.xml> .
What is reflective writing?
Reflective writing is writing which involves '… consideration of the larger context, the meaning, and the
implications of an experience or action' (Branch & Paranjape, 2002, p. 1185). In medical and health
science courses you are required to produce reflective writing in order to learn from educational and
practical experiences, and to develop the habit of critical reflection as a future health professional.
Reflective writing may be based on:

description and analysis of a learning experience within the course:
o a community placement
o a clinical placement
o a rural placement



description and analysis of a past experience
review of your learning or course to that point
description and analysis of a critical incident.
What is a 'critical incident'?
A critical incident need not be a dramatic event: usually it is an incident which has significance for you. It
is often an event which made you stop and think, or one that raised questions for you. It may have made
you question an aspect of your beliefs, values, attitude or behaviour. It is an incident which in some way
has had a significant impact on your personal and professional learning.
In the university setting, a critical incident might include:





an aspect of your project or group work that went particularly well
an aspect of your project or group work that proved difficult
a piece of work that you found particularly demanding
a piece of work which increased your awareness, or challenged your understanding, of social
justice issues; or
an incident involving conflict, hostility, aggression or criticism (Fook & Cooper, 2003).
In the clinical setting, a critical incident might include:








a medical emergency
an unusual condition
a difficult situation
a communication problem (eg. with a patient or colleague)
an interaction with a patient which made an impression on you (either positive or negative)
an incident that made you feel inadequate in some way
a time when you felt confronted; or
an incident which made you think differently, or caused you to question your assumptions or
beliefs.
Critical incidents may relate to issues of communication, knowledge, treatment, culture, relationships,
emotions or beliefs.
Critical incident analysis
When analysing a critical incident, it is useful to ask yourself questions such as:





Why do I view the situation like that?
What assumptions have I made about the client or problem or situation?
How else could I interpret the situation?
What other action could I have taken that might have been more helpful?
What will I do if I am faced with a similar situation in the future?
The reflective learning process
What is the role of reflection in the learning process?
Students sometimes view reflective writing as an annoying interruption to the serious business of
developing content knowledge in their subject area. However, there are sound reasons why reflective
writing is included in student assessment.
"Reflection is indicative of deep learning, and where teaching and learning activities such
as reflection are missing… only surface learning can result."
Biggs 1999 in King 2002
Reflective writing tasks are given to students to help students learn through reflection, precisely because
of the established link between reflection and deeper learning. As well as facilitating learning and
monitoring learning, the intention is to produce graduates who have acquired the habit of reflection as a
means of continuing to learn and grow in their professions. Reflection can lead to:



personal growth
professional growth
meaningful change.
"Reflection leads to growth of the individual – morally, personally, psychologically, and
emotionally, as well as cognitively".
Branch & Paranjape, 2002, p. 1187
Reflection can help you to:






better understand your strengths and weaknesses
identify and question your underlying values and beliefs
acknowledge and challenge possible assumptions on which you base your ideas, feelings and
actions
recognize areas of potential bias or discrimination
acknowledge your fears, and
identify possible inadequacies or areas for improvement.
Reflection can lead to greater self-awareness, which in turn is a first step to positive change – it is a
necessary stage in identifying areas for improvement and growth in both personal and professional
contexts. Taking time to reflect can help you identify approaches that have worked well, and in that way
reinforce good practice.
Conditions for reflection
You should be thinking about possible subjects and opportunities for reflective writing before and during
your placements, not only after them.
Some conditions which can assist you to learn through reflection include:






Preparation – when you enter into a new experience, try to identify opportunities for reflection.
Understanding – you need to know what the goals and expectations of critical reflection are.
Time to stop and think.
A level of objectivity about yourself and the impact of your actions.
Honesty.
An open, non-defensive attitude to the experience.

A focus on the deeper levels of meaning – moral, ethical, social and/or professional issues
(Branch & Paranjape, 2002) in addition to your emotional response.
Conditions inhibiting reflection
In the workplace, lack of time frequently limits opportunities for learning through reflection. People may
not have time to stop and think. Similarly, time is an issue for students.
For students, perhaps the major obstacle to learning through reflection is devoting insufficient time to it,
and consequently failing to explore the experience in depth. Students sometimes write simply to meet the
assessment requirements, without genuinely engaging in the process.
This will not lead to meaningful insights or positive change.
The action-reflection model
There is a clear link between action, reflection and change within this style of learning. In the activityreflection model there are four stages to the cycle of reflection:




The initial or new experience
Reflection and observation
Development of a new concept
Experimentation.
Format for the critical incident report
In the MBBS (Bachelor of Medicine/Bachelor of Surgery) you are asked to write a Critical incident
report. Here is a suggested format for this report.
1.
2.
3.
4.
5.
6.
7.
8.
Describe the context of the incident.
Describe the actual incident in detail.
Explain why the incident was critical or significant for you.
Explain your concerns at the time.
Describe what you were thinking and feeling as it was taking place, and afterwards.
Mention anything particularly demanding about the situation.
Explain how the incident will impact on your studies.
Explain how it will impact upon your future role as a health professional.
Sample critical incident report
The writing style required in producing a critical incident report is different from that of an academic essay;
however, it is still important to present ideas in a systematic and organised way, and to use appropriate
language. The sample below uses sub-headings consistent with the assignment requirements to explicitly
organise the report. It is simply written, and avoids use of jargon or colloquial language.
Click on the highlighted text to see the comments.
Context of the incident
This report will outline a critical incident which occurred in Week 9, Semester 2 in my clinical tutorial. The
incident was initiated by my tutor, who announced that she would provide individual feedback to students
on their performance in clinical tutorial discussions. She also stated that she would be producing written
comments on each student's behaviour, attitude and contribution in tutorials to be incorporated into
student portfolios for Semester 2.
Details of the incident
At the end of my clinical tutorial my tutor arranged for us to meet briefly in order for her to discuss her
feedback with me. [1]She stated that over the semester she had noticed that I very rarely spoke in the
tutorials and did not appear to engage with the other students. She was concerned that I appeared to lack
confidence, and explained that being able to express opinions clearly and confidently was essential in my
future career as a doctor. In her view the only way to develop confidence was to participate regularly. She
asked me how I felt about this, and if there was a reason why I almost never spoke in class. [2]I explained
that in my culture students were not always encouraged to speak, and for that reason I did not find it
easy. I also mentioned that I sometimes feel shy.
Thoughts, feelings and concerns
At the time of this incident, many emotions were running through me. I felt embarrassed that my lack of
confidence was so obvious to her, and also concerned about what impact it might have on my results. I
was worried that she would write negative comments about my behaviour and attitude, and that these
comments would be available for other lecturers to read. At the same time, I realised that her concerns
were justified – I had been aware of my lack of contribution throughout the semester, and had even
avoided going to some tutorials because of those feelings. This was also an unfamiliar situation for me,
as I had always done very well at school and achieved good marks, so I had never had to talk with a
teacher in this way before. Although I understood that her intention was to help me to do better, I felt very
uncomfortable and even ashamed to have to acknowledge my poor performance in this area. I felt guilty
when I realized that in her opinion I had contributed so little to the class.
Demands
This incident was very demanding because it forced me to acknowledge an area where I have always
lacked confidence. Even though I preferred to focus on other areas, I knew that my tutor would be
noticing my behaviour in tutorials over the rest of the semester, and that her written comments would
depend on my performance, so as a consequence I felt under pressure. I also felt anxious about
confronting this issue and trying to develop the confidence I needed.
Impact on studies
Although this incident caused me discomfort and added pressure in the short term, I realise that it was a
very significant event in my studies. As a result of the conversation with my tutor I was forced to
reconsider my behaviour in tutorials and became more aware of how others viewed me. I had been used
to think that I was 'invisible' in tutorials, but now I realised that not talking actually made me stand out
more. Fortunately, the tutor gave me advice on how to gradually develop the confidence I needed, and I
also sought help from some of my friends. I even organized to have some informal tutorials with friends to
give me a chance to practice. Over the final weeks of the semester I managed to talk at least once in
every clinical tutorial, either asking a question or making a comment. I have started trying to talk in other
tutorials also, in other subjects. I have set myself the goal of talking at least once every tutorial.
This incident was therefore very important, because without it I would still be remaining silent in my
tutorials, and would have received negative written comments from my clinical tutor in my portfolio. More
importantly, it has helped me to acknowledge and work on an area for improvement which will be
beneficial in all aspects of the course. Developing greater confidence at speaking in tutorials may lead to
me being more confident in performing clinical examinations on patients. It may also lead to me feeling
more in control and [3]experiencing less nerves during my Objective Structured Clinical Examination
(OSCE) assessments.
Impact on career
My tutor was right in stating that a doctor must be able to express opinions clearly and confidently. Good
communication skills are essential for doctors, and are important in nearly all aspects of medicine. I feel
that I will be more confident in dealing with patients and more effective in taking a patient history, for
example. Developing greater confidence in how I communicate can lead to patients having greater trust in
me as their doctor. Improving my skills in this area will also make me more effective in discussing cases
with colleagues, and in participating in teams when necessary.
This incident made me realise that I can talk confidently once I overcome my initial fears. It demonstrated
to me that in order to make progress or create positive change you must first acknowledge that a problem
exists. This is a lesson which may be useful in better understanding patient behaviour and attitudes.
Often the first step to improving a situation, or dealing with a problem, is accepting that some change is
necessary; and I may be more able to impart this information to patients having experienced this incident.
Overall, this incident has had a positive impact on both my studies and on the development of skills
needed in my future career.
[1]
Note the use of reported speech to describe the conversations between those involved in the incident.



She stated that…
She was concerned that…
In her view…
[2]
Note the use of first person to describe the writer's reactions and feelings:





I explained…
I mentioned…
I felt embarrassed…
I was worried that…
I realised that…
[3]
Expression: it might be better to say 'less nervous' or 'have fewer nerves'.
Criteria for assessment
Reflective writing is a vehicle which you use primarily to share your thinking and learning processes with
your lecturers. The event or incident or experience in itself is not important – what is important is your
reaction to it, and how it has informed your thinking and your learning. Assessment tends to focus on how
successfully you have demonstrated a capacity to analyse and reflect on events in order to learn from
them. Also relevant to assessment is how much you are able to relate your current theoretical learning
(for example, about the doctor-patient relationship, or about what constitutes effective communication) to
a real life situation.
Most importantly, you need to be genuine and honest in your reflections, as illustrated in the following
quote from a lecturer:
The most important thing to get across to the students is that they be genuine in their
reflections, and not write what they think I want to hear. For example, empty rhetoric like
'this incident has made me want to go and work with people in developing countries',
'since this incident I have decided to be the best doctor I can possibly be' or 'in future I
will treat my patients holistically' does not score points.
Common errors in reflective writing
1. Planning
You should be thinking about possible subjects and opportunities for reflective writing before and during
your placements, not only after them.
2. Writing style
Writing too informally: just because it is based on your experience does not mean you can ignore
academic style.
Example
Writing style comparison
Original text
Alternative text
In my opinion, if there are too many 'buts' in my
choosing to practice in a rural area then I must
not be ready for it, so it's better for me to stay put
in the city.
The reservations I currently feel about practicing
in a rural setting suggest that I am not yet ready
for such a move. So at this stage I plan to work in
the city on graduation.
3. Too little or too much detail
You need to describe the experience adequately – the reader needs to be given enough detail to
understand the context in which the experience occurred. However, it is not enough just to describe the
experience in great detail: you also need to analyse and evaluate the events and the thinking processes
involved. You should aim to consider deeper levels of meaning, exploring moral, ethical, social and/or
professional issues.
Take time to organize and structure your writing. Try to focus on what was most significant about the
experience, and relate it to aspects of your course and future career. Be careful that your writing does not
seem to simply drift without direction or focus.
4. Being judgemental
Try to describe events accurately and honestly, but avoid moralising about people's behaviour.
Example
Being judgemental – comparison
1.
Original text
Alternative text
I was shocked when the doctor showed me
the patient's file without seeking consent.
His disregard for the rules regarding patient
consent caused me to lose respect for him
and to question his ethical standards.
I was surprised when the doctor showed me
the patient's file without seeking consent. It
made me realise that discrepancies can
exist between what is taught on course and
the way in which medicine is practised in
reality. From my own perspective, as a
future doctor I would seek to maintain high
ethical standards, and to encourage that
among staff under my supervision.
During the second week of my clinical
study, I met a patient who needed an x-ray
for her knee and hip joint. She was
overweight and not very aware of my role
as radiographer – she treated me more like
a technician than a future doctor. Even
worse, she was not cooperative, kept
murmuring and shouted out about her pain
throughout the procedure. Furthermore, this
patient didn't listen to our instructions and
wouldn't stay still after positioning.
2.
During the second week of my clinical
study, I met a patient who needed an x-ray
for her knee and hip joint. This was made
more difficult because she was significantly
over-weight and not very aware of my role
as radiographer. She appeared distracted
and had difficulty coping with her level of
pain, sometimes shouting out. In terms of
the x-ray procedure the patient was
uncooperative – she did not follow our
instructions and would not stay still after
positioning. This made it very difficult to
produce an adequate x-ray.
It could be useful to analyse this incident
further – for example:
What surprised me most about this incident
was the attitude of the patient to the health
professionals. In my culture most people
treat health professionals with great
respect, and acknowledge their authority;
they are even sometimes intimidated by
them. I realised that in the Australian
context compliance from the patient cannot
be assumed. The doctor has to gain the
trust and cooperation of the patient, and this
may not always be easy. In this case I
found that talking quietly to the patient and
explaining each requirement in detail
reassured her, and ultimately led to a
greater level of cooperation. However, this
made the consultation much longer than it
otherwise would have been.
Characteristics of reflective writing
This section covers the language features of reflective writing:



tenses <www.monash.edu.au/lls/llonline/writing/medicine/reflective/8.1.xml>
speculative and hypothetical writing
<www.monash.edu.au/lls/llonline/writing/medicine/reflective/8.2.xml>
the language of self-reflection vs criticism
<www.monash.edu.au/lls/llonline/writing/medicine/reflective/8.3.xml> .
Tenses
Reflective writing often requires movement between past and present tenses, depending on whether you
are recounting the actual events or making a more general comment (for example, on the doctor-patient
relationship, or on an aspect of your current course).
Generally, when recounting a particular experience or incident, past tense is used.
Example 1
As part of my placement at the Echuca Base Hospital I worked closely with the nursing staff. I was
impressed by the rapport they had with their patients – while performing their duties professionally
they often joked with the patients, and in that way maintained a relaxed and pleasant atmosphere on
the ward. I noticed that the nurses had more regular contact with patients than the doctors, and
consequently seemed to develop a closer relationship.
Example 2
When two of the patients became agitated I did not know what to do. I asked them to return to their
beds, but they simply ignored me. I did not know what the correct procedure was in this situation.
When making a general comment, or relating an incident to current practice or to a particular theoretical
perspective, present tense is normally used.
Example 3
It seems that the roles of nurses and doctors are quite different, and that doctors need to
acknowledge the importance of the nurse-patient relationship.
Example 4
Clearly making new staff aware of the procedures and rules is important when they join a new
workplace or institution.
Continue Example 4 by linking what you have learnt from an incident directly to how you plan to
behave in your future career. Try adding 1 or 2 more sentences to Example 4.
Feedback:
It's always good to stop and reflect on what you have written. Have your views been affected by your
personal or professional experiences? Think about your use of tenses. Check that you have written your
reflections in a non-judgemental way.
Speculative and hypothetical writing
In reflective writing you may be asked to speculate about the future, or about a hypothetical situation. For
example, you may be asked to comment on whether you would like to practice in a rural area in your
future career.
Notice in the example below the movement between past and present tenses, and the use of 'would'
when speculating about the future.
Example 5
Although my rural placement was a very positive experience, I would not like to work in the country
when I first graduate. There are several reasons for this. Firstly, being a country doctor is more
challenging – you do not have the support networks available in the city, so you have to cope with
many different situations. Also, you have less privacy. In the country I would have to behave as the
local doctor all the time, 24 hours a day. There would not be an opportunity to just be myself and not
worry about what people think. Living in the country I would be far away from my family, and might
feel lonely for that reason. Finally, I would have to focus on general practice, whereas my interest lies
in more specialized areas of medicine.
Example 6
As soon as I started there, I could see that having a good working relationship with the nurses would
make my job much easier, and would possibly result in better health care for patients.
Self reflection v self criticism
Some writers become confused between self-reflection and self-criticism. You need to go beyond simply
admitting a weakness or mistake or failure – what is important is not only what you did, but how you felt,
what you have learnt from that experience, and how it will inform your behaviour in the future.
Addressing course issues and topics
Try not to confine your writing to the event and your feelings. If possible, use it to raise new questions or
to speculate about possible causes and solutions. Remember where possible to link your reflections to
theoretical aspects of your course. For example:
Addressing course issues and topics – comparison
Original text
Alternative text
When the doctor raised his voice to the patient I felt
embarrassed and the patient appeared to feel humiliated.
Clearly this behaviour by the doctor was not appropriate,
even though the doctor was obviously frustrated at the
When the doctor raised his voice to the
patient's apparent inability to understand the instructions.
patient I felt embarrassed. It reminded
While it is the responsibility of every doctor to behave
me to maintain an appropriate
respectfully with patients, on this occasion an excessive
communication style with patients when
workload and the lack of availability of an interpreter no
I am a doctor.
doubt contributed to the doctor's behaviour. It reminded me
that structural factors within the health care system, such as
staffing and budgets, can impact on the quality of attention
delivered to patients.
Other reflective writing resources
Branch (Jr), W.T., & Paranjape, A., 2002, 'Feedback and reflection: Teaching methods for clinical
settings', Academic Medicine, Vol. 77, No. 12/Dec, Pt 1, pp. 1185-1188.
Whipp, J., 2003, 'Scaffolding Critical Reflection in Online Discussions', Journal of Teacher Education, Vol.
54, No. 4, pp. 321-333.
King, T., 2002, Development of Student Skills in Reflective Writing, University of Portsmouth, UK, viewed
27 November, 2006, http://www.csd.uwa.edu.au/iced2002/publication/Terry_King.pdf
<www.csd.uwa.edu.au/iced2002/publication/Terry_King.pdf> .
Fook, J., & Cooper, L., cited in (2003) Bachelor of Social Work Fieldwork Manual, Dept. Social Work,
School of Primary Health Care, Monash University.
Writing in Psychological Medicine
Written case report
The written case report is an opportunity for students to demonstrate that they have developed a
comprehensive formulation and a management plan for a patient that they have personally interviewed.
Click on the highlighted text to see the comments.
See the [1]full assessment description here.
[1]
The case report should record a thorough assessment, demonstrate the student's capacity to appreciate
the patient's experience, present an attempt to understand why this patient is ill in this way at this time,
and describe what management will be required to facilitate this patient's return to best possible
functioning.
To this end, it is expected that the student will:






Present a document which communicates in a clear and orderly fashion
Provide appropriately selected historical and examination material, including both positive and
negative findings relevant to the case
Indicate an awareness of the limitations of the material obtained and presented
Demonstrate an awareness of the range of diagnostic issues which need to be considered
Present a formulation, drawing together the historical and examination material, so as to develop
an understanding of the patient
Provide a management plan considering the immediate, short-term, and longer term issues
presented by this patient
There is no word limit on the report - the content should be both sufficient and well edited. The judgement
on what to include is part of the professional skill under development.
This is a psychological report and therefore the emphasis is on the psychological issues. Note that this
does NOT imply the exclusion of medical issues!
Report structure for writing in Psychological Medicine
The information provided in this resource will assist you with structuring information, communicating
reasoning, and checking your application of English grammar in the Psychological case report.
The report structure is based on recommendations outlined in the recommended reading for this
assignment task:
Bloch, S., and B.S. Singh (1991). Foundations of Clinical Psychiatry (2nd Ed.).
Melbourne: Melbourne University Press, Chapter 6.
Overview
1. Case History <www.monash.edu.au/lls/llonline/writing/medicine/psychology/2.xml>
1. 1.1 Introduction
2. 1.2 History of Presenting Complaint
3. 1.3 Past Psychiatric History
4. 1.4 Past Medical History
5. 1.5 Family History
6. 1.6 Personal History and Development
2. Mental State Examination <www.monash.edu.au/lls/llonline/writing/medicine/psychology/3.xml>
3. Physical Examination <www.monash.edu.au/lls/llonline/writing/medicine/psychology/4.xml>
4. Summary and Diagnosis <www.monash.edu.au/lls/llonline/writing/medicine/psychology/5.xml>
5. Formulation <www.monash.edu.au/lls/llonline/writing/medicine/psychology/6.xml>
6. Management <www.monash.edu.au/lls/llonline/writing/medicine/psychology/7.xml>
Case history structure
1. Case History
1.1 Introduction
An introduction is necessary to establish the focus of your case and provide orientation to your reader. It
should consist of a few clear and concise opening statements, which typically include information on:






Name (pseudonym)
Age
Marital status
Occupation
Referral details
Central problem
Sample text and writing tips <www.monash.edu.au/lls/llonline/writing/medicine/psychology/2.1.xml>
1.2 History of Presenting Complaint
This should be a detailed account of the patient's central problem that you have already identified in your
opening statement. Put details about the problem and related symptoms in a chronological order, as this
will help with the clarity of your writing.




Identify common psychiatric symptoms
You should make connections between the isolated symptoms that the patient may have
revealed to you somewhat randomly in their interview by grouping the symptoms together (i.e.
depressive, psychotic, anxiety). This will help your writing to develop logical sequences. It may be
necessary to comment on relevant negative as well as positive symptoms.
Comment on the impact of the illness on the patient's life
Consider work, social relations and self-care.
Note details of previous treatment
Include information on who administered management (when and where), what the treatment
was (and preferably the dose and duration of treatment), and the patient's responses to
treatment.
Integrate current problem and psychiatric issues
Consider the relationship between the patient's psychiatric state and concurrent medical
conditions
Sample text and writing tips <www.monash.edu.au/lls/llonline/writing/medicine/psychology/2.2.xml>
1.3 Past Psychiatric History
"Many psychiatric illnesses are recurrent or have an acute-on-chronic course, so that the
link between the present illness and past psychiatric history may be strong. This is the
rational for describing the past psychiatric history immediately after the present illness."
Bloch and Singh (2001: 91)
The following points are relevant in this section:





details of previous episodes of illness
previous psychiatric admissions/treatment
outpatient/community treatment
suicide attempts/drug and alcohol abuse
interval functioning (what is the patient like between episodes/when "well')
By including this sort of information, you will build a picture of the pattern of illness (chronicity, severity,
coping strategies, crisis triggers, etc.), which will contribute toward a complete discussion of the illness.
Sample text and writing tips <www.monash.edu.au/lls/llonline/writing/medicine/psychology/2.3.xml>
1.4 Past Medical History
In this section of the report, you need to show that you a) understand the relationship between medical
conditions and psychiatric symptoms, and b) can appreciate the complexity of medical problems that
might be exacerbated by psychiatric conditions.
Record medications. Demonstrate an understanding of the significance of drug therapy on psychological
function and, if appropriate, focus on medications taken by the patient that may influence the patient's
psychological function.
Sample text and writing tips <www.monash.edu.au/lls/llonline/writing/medicine/psychology/2.4.xml>
1.5 Family History
Include details of:



Parents and siblings, nature of the relationships between family members
Any family tensions and stresses and family models of coping
Family history of psychiatric illness (incl. drug/alcohol abuse, suicide attempts)
Include a geneogram (drawing of family tree).
1.6 Personal History/Development
Use the list in Bloch and Singh (2001:93) as a guide for selecting and organising the information in this
section:













Early development
Childhood
School
Adolescence
Occupation
Menstrual history
Sexual history
Marital history
Children
Social network
Habits
Leisure
Forensic history
Keep notes for each subsection brief. In particular, note a) any problems the patient may have
experienced with adjusting to predictable stages of development (e.g. - but not restricted to - effect of
medical and psychiatric illnesses on development), and b) how they responded to stressful life
circumstances.
If possible, comment on the patient's personality traits prior to their illness (i.e. premorbid personality).
Introduction examples
Example 1:
Bloch and Singh, 2001:90
Julie, a 25-year-old single accountant, and a practising Jehovah's Witness, lives with her retired
parents. She was referred by her family doctor with an abrupt onset of psychotic symptoms. This
followed two weeks of lowered mood after the break-up of her first ever relationship, which was with a
co-worker who unexpectedly left to travel overseas.
Example 2:
Student's report
Lucy is a 34 year-old single mother who is living with her fiance and her 5 year-old son. Lucy was
referred to the Monash Medical Centre by her general practice with a 4-week history of headache, the
symptoms of which were so bad that she forced to resign from work. A subsequent CT scan indicated
the presence of a tumour in the right frontal lobe. Upon the CT diagnosis, Lucy experienced symptoms
of depression and anxiety, which have progressively worsened. She is now awaiting the results of a
cranial biopsy.
Example 2:
Student's report
Mrs P, a 68 year-old married housewife, lives with her husband on a farm. She presented to the
Emergency Department at the Monash Medical Centre with diarrhoea and moderate dehydration
following bowel resection two weeks earlier to remove carcinoid tumours. This follows a two-and-a-half
year history of diarrhoea and weight loss, which has seen Mrs P become increasingly housebound
and more dependent on her husband, who suffers Tourrett's syndrome and depression, for care. Her
current critical state follows closely on the suicide of her youngest daughter (aged 39 years) in March
this year.
Writing tips:
The Introduction is different to the Summary that comes at the end of the report. It is much briefer (2-5
sentences) and is designed to set the scene for your reader. In it, you will establish the current presenting
complaint and emphasise likely causal elements. You may specify a diagnosis, especially if this is
relevant to the presenting complaint and is established prior to the current presentation or is known at the
time you conduct the interview with the patient. It is less likely to include data from sections other than the
history of the presenting complaint (and past psychiatric history where relevant).
History of presenting complaint examples
Click on the highlighted text to see the comments.
Example 4:
Bloch and Singh, 2001:90
[1]The
patient describes an eight-month history of anxiety symptoms, which began two months after a
car accident. [2]She experiences apprehensiveness when out of her home, inability to cope with
anything out of the ordinary, initial insomnia and irritability, and she has withdrawn socially. [3]More
recently she has had trouble concentrating on her work. [4]Five days ago she was taken to her local
GP after experiencing a typical attack in the supermarket. She has become housebound since,
ruminating that "I'm terrified of suffering a heart attack and dying suddenly like my mother". [5]She has
begun drinking up to a bottle of wine a day in an effort, she says, [6]"to calm myself down and make
things more bearable".
Writing tip 1:
You may choose to commence this section of the report with a summary of the key issues that you will
address, as in the example shown.
The central problem is identified promptly in the first sentence, and relevant key symptoms are outlined
immediately in the second sentence. This is important information in an objective diagnostic work-up.
Information on the impact of illness is placed next, helping to contextualise the patient's experience of the
central problem and related symptoms. This information will contribute toward a more sophisticated
diagnosis that accommodates the patient's experience and response to illness.
Note that in the example all symptoms (whether present or not) relevant to a diagnosis of anxiety and the
differential diagnosis) have not been included. This is OK for an introduction but not for the history of
presenting complaint.
Writing tip 2:
Chronology is established using three techniques.
1. The opening sentence not only identifies the central problem but also informs the reader of when
the problem first started. This establishes a temporal perspective on the patient's current
problem, which is relevant for framing the events when describing the course of the problem.
Remember, in this instance, we are referring to the patient's current problem or episode, which
may or may not be related to an underlying chronic condition. This means that, having alerted the
reader to the fact that this presentation/episode is part of a longer-standing problem, the current
episode is described first and then the remainder of the illness course beginning with the first
onset of symptoms. This would usually be put in the history of the presenting complaint.
2. Events are placed in chronological order, which is regularly marked by the use of specific
temporal markers, highlighted in the example ( e.g. an eight month history... began two months
after, more recently, five days ago, since). This is preferable to a specific date (as the reader then
has to calculate the duration).
3. Temporal perspectives on actions, events, and states of affairs are marked grammatically by
appropriate use of English verb tense forms (see notes on Example 5.).
[1]
Comment 1
Central problem
[2]
Comment 2
Common psychiatric symptoms
[3]
Comment 3
Effect on work
[4]
Comment 4
This is the precipitant
[5]
Comment 5
Impact of illness on work, social relations, and self-care
[6]
Comment 6
The history is documented from the patient's perspective. The facts recorded must be based on the
patient's description. Where appropriate, incorporate the patient's own words into the report.
Past psychiatric history examples
Click on the highlighted text to see the comments.
Example 4:
Student's report
Lucy has a 4-week history of severe headache. Initially, Lucy reported a disturbance in her vision,
saying that she saw "purplish-black colour spots" in her vision. This was followed by the onset of a
severe headache located at the right frontal and temporal regions, radiating to the right occipital area.
The headache commenced as mild and dull pain then became severe and throbbing in nature. It was
worsened by straining and coughing. Lucy likened the pain to "being stabbed and squeezed by
someone continuously" and described the headache as the most horrible she had ever had. Lucy's
GP prescribed her Panadol. The medication did not help and Lucy started to experience nausea,
vomiting, and mild photophobia. She also experienced pain at the nape of her neck.
2 weeks after the headache commenced, Lucy was referred to an ophthalmologist. An angiogram
showed signs of venous blockage in the retinal veins. The headache persisted, and 3 weeks after it
commenced, Lucy was becoming more worried about it. She was experiencing (4)sleep disturbance,
poor appetite and weight loss (she reports losing 5kg over three weeks). At the time, Lucy resigned
from work, thinking that her symptoms were stress-related and she probably needed a break. Lucy
also sought a second opinion from another GP. A CT scan revealed a tumour in the right frontal lobe,
which was causing oedema and a mid-line shift. [1]Lucy was immediately admitted to MMC for biopsy
of the tumour.
Since receiving the diagnosis of neural tumour, Lucy has felt depressed and anxious about her health.
Lucy has experienced two nights of restless sleep. She has lost enthusiasm for her usual activities,
such as going shopping and taking care of her son. She reports having no energy for maintaining her
work or social life. She has also become more irritable and aggressive, which is putting additional
pressure on her family. She admits to being preoccupied with thinking about her illness and is having
trouble concentrating on daily activities. [2]She reports feeling tired but too scared to sleep for fear that
she will not wake in the morning.
In conjunction with her depressive symptoms, [3]Lucy is also experiencing excessive anxiety. Her
anxiety is associated with restlessness, tiredness, irritability, insomnia, and difficulty in concentrating.
Other symptoms include palpitations, tachycardia and flushing. Lucy expresses concern over the
impending biopsy report, due sometime in the next two days, asking, "Am I going to die? Does the
tumour mean cancer?" [4] Lucy also expresses concern over her son's welfare while she is
hospitalised. In the last month, her fiance and her mother have been looking after both her and her
son.
(428 words)
Writing tip:
In reporting past events, your choice of English tense-aspect will allow you to add your perspective on the
current relevance of the patient's symptoms, signs, and experiences.
Incorrect use of tenses and time markers impacts on temporal sequences, which influences the logical
structure of the text and may even influence clinical interpretations of illness.
In the example shown, note how the history is reported chronologically, starting with an account of most
distant past events and culminating in events and circumstances existing in the present time (i.e. at the
time of the interview). Note how the tenses shift through the report.
[1]
Comment 1
The report commences with an account of events in the past. In the first two paragraphs, events and
experiences are predominantly expressed in the past tense. The past tense is used to refer to:

Events in the patient's history that occurred prior to the interview and are squarely placed in the
past. Although related to the Presenting Complaint, the assumption of relevance to the current
presentation is no longer immediate (compare with the use of the present perfect tense, below)
"Initially, Lucy reported a disturbance in her vision..."
"Lucy's GP prescribed her Panadol. The medication did not help and Lucy started to
experience nausea, vomiting, and mild photophobia."
[2]
Comment 2
The report moves closer to present time. In the third paragraph, the present perfect tense predominates.
The present perfect tense is used to refer to events in the patient's history that occurred prior to the
interview but still bear current relevance.



In the history, you may describe signs and symptoms that began in the past and are still
continuing.
"Since receiving the diagnosis of neural tumour, Lucy has felt depressed and anxious about her
health. She has lost enthusiasm for her usual activities, such as going shopping and taking care
of her son."
You may describe signs and symptoms that no longer exist but that have an impact still felt in the
present (i.e. they were experienced a short time ago)
"Lucy has experienced two nights of restless sleep."
You may describe completed events whose impact remains significant in the present situation.
"The physician has diagnosed a tumour in Lucy's right frontal lobe."
[3]
Comment 3
The final paragraph brings the account of events and experiences into present time.
The simple present tense is used to describe:


Events occurring at the time of the interview with the patient, including the patient's verbal
reporting
"Lucy expresses concern..."
Habits and permanent states
"Lucy is a 34 year-old single mother who lives with her fiance and her 5 year-old son."
[4]
Comment 4
The progressive tense is used to describe:

Temporary states (symptoms/signs) or situations, either in the past or present time:
"Lucy is experiencing excessive anxiety."
"Lucy was experiencing sleep disturbance, poor appetite and weight loss."
Past medical history examples
Example 4:
Student's report
Lucy has a set of medical conditions that are summarised as HERNS (Hereditary Endotheliopathy,
Retinopathy, Neuropathy and Stroke). 10 years ago, she experienced symptoms of proptosis,
tachycardia, thirst and vomiting and was diagnosed with Grave's disease. She was treated with
Neomercazole. The coexisting medical condition may be exerting an impact on Lucy's current anxious
state. In addition, her apparent poor coping mechanisms, which she has described as part of her
personality trait, might also be facilitating her anxious state.
In 1996, Lucy experienced a minor stroke, which caused temporary paralysis in her left arm. She was
monitored in hospital for three weeks and recovered.
3 years ago, Lucy was diagnosed as lupus carrier. Since the diagnosis, Lucy has been taking Warfarin
and she expects to maintain Warfarin therapy for life. Her condition has exacerbated a series of
endotheliopathies, predisposing Lucy to retinal microvascular occlusion.
2 weeks prior to her current hospital admission, Lucy was also diagnosed with hypercholesterolemia,
a suspected genetic disorder. She is currently taking Lipitol to manage this.
Writing tip 1:
Significant events in the Medical History are placed in chronological order, which helps with clarity of
reporting.
Specific dates are used to help establish chronology clearly and succinctly.
Writing tip 2:
In this section, the simple past tense predominates but tenses shift when events bear significance to the
patient's present context.
Refer to earlier points made, under notes to Example 5, on the use of English tense in case
presentations.
For example:


"Since the diagnosis, Lucy has been taking (present perfect continuous) Warfarin and she
expects (present) to maintain Warfarin therapy for life."
"Her condition has exacerbated (present perfect) a series of endotheliopathies. She is currently
taking (present continuous) Lipitol to manage this."
Click on the highlighted text to see the comments.
Example 5:
Bloch and Singh, 2001:92
[1]The
patient, the eldest in a family of three daughters, still lives at home. [2]Her mother, a 45-year-old
primary-school teacher and her father, a 50-year-old electrician, [3]are described as strict and intrusive,
a pattern she ascribes to their strong Catholic beliefs. [4]Their marriage is described as 'over years
ago; they never talk or touch' and [5]the atmosphere at home as tense. [6]The patient is close to her
younger sister in whom she confides. One sister has responded [7]to a similarly distant relationship
with both parents by getting married after a whirlwind romance, the other by moving to another city.
[8]Her mother was hospitalised with post-natal depression twenty years ago. There is no other family
history of psychiatric illness.
Writing tip 3:
In Australian culture, when a person is married with children and living away from the parental home, we
tend to think of the family unit as comprising the couple and their children. In other words, the couple, as
parents, head the so-called nuclear family unit.
In some cultures, though, we place emphasis on one's own parents in family structures. Hence, even
when a person is married with children and living away from the parental home, we may think of the
family unit as incorporating the extended family and continue to emphasise an individual's parents as the
head of the family unit, which is larger than the nuclear family unit.
Obviously, your perspective on family unit will influence the way you report on the patient's family
relationships. As stated above, in Australian culture, while relationships with one's parents are integral to
an individual, we tend to view the family unit as consisting of principally the couple and their children.
Hence, the couple is at the head of the unit, while the couple's relatives, including their parents, comprise
the extended family. Consequently, in your report, in such a situation, you would focus immediately on
discussing the patient's relationships with their partner and children before moving on to discuss their
relationships with their parents and siblings. If the family unit is different, and larger, then you will need to
consider your approach to reporting on the patient's family relationships. Do not occupy unnecessary
space by reporting on all the familial relationships if the family is a large one and do not defer discussion
of the patient's relationship with their partner and children (it is probably one of the most influential).
[1]
Comment 1
Family size
[2]
Comment 2
Parents' ages and occupations
[3]
Comment 3
Parents' personality characteristics
[4]
Comment 4
Parents' marital relationship
[5]
Comment 5
Family atmosphere
[6]
Comment 6
Special relationship
[7]
Comment 7
Parents' relationship with children
[8]
Comment 8
Family history of psychiatric illness
Mental state examination structure
2. Mental State Examination (MSE)
Use the headings in Bloch and Singh (2001:94-105) to organise your notes:
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General appearance and behaviour
Speech
Affect and mood
Quality
Range
Appropriateness
Depersonalisation and derealization
Thought (stream, form, content)
Perception
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
Cognition
Judgement
Insight
Rapport
Sample text and writing tips <www.monash.edu.au/lls/llonline/writing/medicine/psychology/3.1.xml>
Mental state examination examples
Example 11:
Student's report
General appearance and behaviour
Lucy is a 34 year-old Indian-Portuguese woman of average weight and height. At the time of
examination, she was well groomed and dressed. She was not confined to bed. On appearance, were
no signs of tremor or abnormal movements; however, Lucy showed signs of proptosis, consistent with
Grave's disease. Lucy was cooperative throughout the interview. She maintained eye contact, except
during the times when recounting the history of her father's death and her previous marriage. Then,
she appeared depressed.
Speech
Lucy articulated herself clearly. She answered questions spontaneously, although at slow rate and
speed. She spoke softly throughout the conversation, particularly when mentioning past unhappiness.
Affect and mood
Lucy's affect was depressed and her range of mood reduced. She also appeared anxious and irritable.
Thought
a. Stream
Lucy's thought stream was decreased. It was also disturbed and Lucy's speech slowed down and
content reduced significantly when mentioning past unhappiness. b. Form
Lucy did not exhibit any formal thought disorders. She was able to answer questions spontaneously
and directly. She did not use any new or created words. Lucy did experience thought block when
exploring sensitivities in her past. No negative thought disorder was detected. c. Content
Lucy was depressed and anxious about her health. She was obsessed with knowing her biopsy result
and was constantly asking the doctors and nurses for her result. Thoughts that the tumour could be
cancer were causing Lucy to lack motivation and feel restless. Lucy was also feeling guilty for not
being able to care for her son and fiance since having the headache. Other than feeling obsession
and guilt, Lucy has no other positive symptoms, such as delusions, phobias or compulsions. Suicidal
ideation was not detected.
Perception
Lucy exhibits normal perception. Symptoms, such as illusions, misinterpretations, depersonalisation,
passivity phenomena, were not elicited.
Cognition
Lucy was alert and orientated to time and place. She was able to answer questions and recall her past
without difficulties.
Insight and judgement
When questioned about her condition, Lucy accepted the fact that she is ill and requires treatment.
She has cooperated with doctors and nurses and is compliant with management.
Writing tips:
You may use the simple past tense to describe the patient's state at the time of the MMSE, as in Example
11. This emphasises that the exam findings are specific to the time of conducting the MMSE, but
suggests that they are probably subject to change if repeated.
Alternatively, you may use the simple present tense to report the findings of the MMSE. This would
contribute toward a consistent reference point for the report by placing the activity of the MMSE at the
same time as the interview, the findings of which are forming the basis of this report. It would also grant
the MMSE findings more immediate perspective. Over multiple interviews it is important to state at which
point the MSE and MMSE were done, especially if the patient's mental state changes or fluctuates.
Both approaches to reporting the findings of the MMSE are acceptable. It is important to be consistent,
though, in the approach you adopt.
Physical examination structure
3. Physical Examination
Emphasise signs relevant to both the patient's presenting and chronic problems and to differential
diagnoses where applicable.
Note signs of long-term psychotropic drug use.
Also attempt to identify signs that indicate the presence/absence of conditions that may present with
psychiatric complications (i.e. neurological and endocrine disorders, substance abuse).
Sample text and writing tips <www.monash.edu.au/lls/llonline/writing/medicine/psychology/4.1.xml>
Physical examination examples
Example 12:
Student's report
On general inspection, Lucy appeared to be tired. She showed a prominent sign of proptosis. She also
had a few bruises on her left arm, due to frequent cannulation and blood test, and a scar from her
recent biopsy on the right side of her forehead.
On cardiovascular, respiratory and abdominal examinations, no significant signs were detected. Blood
pressure was normal, 130/82. Pulse rate was 80 beats per minute and respiratory rate was 14 beats
per minute.
On neurological examination, there were no signs of muscle wasting, abnormal movements or tremor.
The upper limbs showed full range of active and passive movements. On flexion and extension of the
right arm, however, pain was detected. The patient had normal tone, power, coordination and
sensation in both arms. Reflexes, however, were increased in both arms.
Examination of the lower limb showed normal tone, power, coordination and sensations. Plantar
reflexes in both legs, however, were decreased. There were no signs of abnormal gaits.
Trendelenburg test, Pull test, and Romberg's test all showed negative results.
Writing tips:
You may use the simple past tense to describe the patient's state at the time of the Physical Examination,
as in Example 12. This emphasises that the exam findings are specific to the time of conducting the
Physical Examination, but suggests that they are probably subject to change if repeated.
Alternatively, you may use the simple present tense to report the findings of the Physical Examination.
This would contribute toward a consistent reference point for the report by placing the activity of the
Physical Examination at the same time as the interview, the findings of which are forming the basis of this
report. It would also grant the Physical Examination findings more immediate perspective.
Both approaches to reporting the findings of the Physical Examination are acceptable. It is important to be
consistent, though, in the approach you adopt.
Summary and diagnosis structure
4. Summary and diagnosis
The summary must draw on all areas in the earlier parts of the report. New information cannot be
introduced.
Essentially the summary will contain a brief outline of:
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Who the patient is
What their problems are
What effects the problems are having on the patient
As well as a brief indication of:

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
Why the problems arose (precipitating factors)
How the problems arose (predisposing factors)
Factors influencing progression/ the course of the problems (perpetuating and protective factors)
Features may be drawn from all aspects of the history and examination, and should include relevant
negatives (features of the diagnosis and differential diagnoses that are not present).
The diagnosis will require you to synthesise signs and symptoms in the case report to identify core
problems. You should explicate your reasoning for drawing the links between signs and symptoms and
diagnostic decision-making. In other words, what important aspects in the History, Mental State
Examination and Physical Examination lead you to making the provisional diagnosis? Pick out the
relevant pieces of these sections and make links with the final diagnosis (and differential diagnoses).
One way to approach explaining your reasoning is for you to take each differential diagnosis and write
down the pros and cons evident in the earlier parts of your report that serve to support or discount the
likelihood of the differential diagnosis.
Sample text and writing tips <www.monash.edu.au/lls/llonline/writing/medicine/psychology/5.1.xml>
Summary and diagnosis example
Example 13:
Student's report
Lucy is a 34-year old single mother who has recently been diagnosed with a cranial tumour in the right
frontal lobe. The diagnosis explains her symptoms of persistent and worsening headache over the last
four weeks, which have led her to resign from work and rely more on her mother for support and care.
Lucy has also experienced symptoms of increased intracranial pressure, such as nausea, vomiting,
and mild photophobia. Hence, it is likely that the tumour is a space-occupying lesion, which is exerting
the oedema effect and causing the symptoms that Lucy is experiencing. Taking her age and sex into
consideration, the lesion is most likely to be a primary lesion, single and benign in nature. In addition,
given that Lucy's father died 15 years ago of stroke related causes, her mother and her sister both
have cardiovascular illness, and Lucy has HERNS syndrome, there is a high probability that the
tumour has a vascular cause.
Lucy has become depressed and withdrawn since finding out that she has a brain tumour. In
particular, she is very anxious about the possibility that the biopsy results will show that the tumour is
cancerous. Although symptoms of depression and anxiety are not uncommon in patients threatened
by a diagnosis of cancer, Lucy has a history of feeling melancholy and, significantly, developed
postnatal depression following the birth of her son five years ago. Lucy's response to her current
illness needs to be understood in this context, as it will help to assess how well she will cope with the
forthcoming diagnosis and future management of her illness.
Upon the mental state examination, Lucy exhibited sullen appearance and limited facial expression.
Although articulate, she spoke slowly and softly throughout the interview. Clearly, Lucy has a
depressed affect. Her history of childhood depression in conjunction with her recent history of poor
appetite, sleep disturbance, energy loss, reduced concentration and feelings of guilt indicate that Lucy
is prone to developing a major depressive disorder in response to her current medical condition.
From the information gathered in the history and examination, the following differential diagnosis can
be posited:
1) Major depressive disorder
Lucy's unhappy childhood and psychiatric history of depression support this diagnosis. In addition, she
meets at least five of the DMS-IV criteria on mental state examination.
2) Biological disorder
The tumour in Lucy's right frontal fossa might affect functions of the frontal lobe, which control thought
and personality. Consequently, Lucy's personality traits may be enhanced by such a biological
disturbance, making her more prone to stress and depression.
3) Anxiety
Lucy's sudden confinement in hospital, diminished ability to perform daily activities, and concerns
about her family and health, predispose her to experiencing anxiety, a potential trigger of depression.
Writing tips:
Links are made between symptoms and pathophysiological processes, which help explicate the
reasoning for arriving at a diagnosis:
Lucy has also experienced symptoms of increased intracranial pressure, such as nausea,
vomiting, and mild photophobia. Hence, it is likely that the tumour is a space-occupying
lesion, which is exerting the oedema effect and causing the symptoms that Lucy is
experiencing.
The evidence supporting the diagnosis is provided from information gleaned earlier in the report.


Diagnosis: The tumour is a space-occupying lesion
Supporting evidence: Lucy's symptoms of increased intracranial pressure (nausea, vomiting, mild
photophobia)
Connections between the conclusions reached (diagnosis) and the supporting evidence (signs and
symptoms) are made with illatives, or argument indicators. There are two kinds of argument indicators.
Either conclusion indicators or premise indicators may be used in your text to link the evidence that
supports the diagnosis.
Conclusion indicators are used to introduce a diagnosis after the evidence has been stated.
Conclusion indicators:
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


therefore
so
hence
thus
accordingly
and (so)
Example:
Lucy has also experienced symptoms of increased intracranial pressure, such as nausea,
vomiting, and mild photophobia. Hence, it is likely that the tumour is a space-occupying
lesion.
Premise indicators are used to introduce the evidence that supports a diagnosis:
Premise indicators:

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

because
since
for
given that
for the reason that

granted that
Example:
It is likely that the tumour is a space-occupying lesion because Lucy has experienced
symptoms of increased intracranial pressure, such as nausea, vomiting and photophobia.
Example:
Given that Lucy's father died 15 years ago of stroke related causes, her mother and her
sister both have cardiovascular illness, and Lucy has HERNS syndrome, there is a high
probability that the tumour has a vascular cause.
Formulation structure
5. Formulation
In this part, you should explore in more depth the aetiology of the patient's illness.
You will need to draw on the precipitating, predisposing and perpetuating factors identified earlier in your
summary to define the biological, psychological and social forces that have contributed towards a) the
development of the patient's illness and b) their response to their illness.
A major difference between a summary and a formulation is that the latter seeks to link the pieces of
information as opposed to listing them.
You should draw on relevant pieces of information from earlier parts of your report and consider the
patient's presenting problem in the context of their history of chronic illness. You can also integrate
evidence and concepts from the wider literature; however, your statements should be an understanding of
the patient, not of the literature.
Sample text and writing tips <www.monash.edu.au/lls/llonline/writing/medicine/psychology/6.1.xml>
Formulation example
Example 14:
Predisposing factors
Lucy has a set of medical conditions, which can be summarised as Hereditary Endotheliopathy
Retinopathy Neuropathy and Stroke (HERNS). The syndrome affects the endothelial vessels of the
eyes and brain. Damage of the endothelium affects the biological functions of organs and leads to
vascular disturbance and build-up of necrotic tissue. Lucy is also a lupus carrier - the antibody, lupus
anticoagulant, is associated with arterial and venous thrombosis. Lucy also has high
hypercholesterolemia, a genetic trait. Taking into account all of these biological factors, Lucy is
predisposed towards developing a brain tumour. The fact that her father died of a stroke in his late 40s
increases the likelihood that Lucy's signs and symptoms are genetically linked.
It is perfectly normal for healthy individuals to feel depressed when threatened with a diagnosis of
cancer. However, Lucy's history of depression, 'fragile' personality, and poor coping mechanisms
when faced with emotional problems make her more likely to be predisposed towards developing
more serious forms of depression compared with otherwise healthy individuals.
Precipitating factors
Obviously, the diagnosis of a neural tumour may be directly linked to Lucy's recent onset of anxiety
and depression. The co-current lack of stability in Lucy's life, including concern over the welfare of her
son while she is ill and the loss of her job, may also be contributing towards her recent depressive
symptoms. The timing of her illness is not especially good for Lucy, who is on the verge of committing
herself to a secure relationship, by marrying and providing a 'family' for her son.
Perpetuating factors
Lucy's experience of one illness after another has left her feeling insecure and with a sense of defeat,
reflected in her personality. Lucy has a weak character in that she has poor frustration tolerance and
coping mechanisms, causing her to emotionally collapse in stressful situations. Her weak personality
is, therefore, a perpetuating factor contributing towards the worsening of her current condition.
Writing tips:
Predisposing factors are the factors in the patient's history that make the patient susceptible or inclined
toward presenting with, where applicable, an underlying diagnosis, and has "these symptoms" in this
current situation.
Precipitating factors are the immediate factors or events that have caused the patient to present with or
experience symptoms now. Depending on their backgrounds, life experiences, supports, coping
strategies, and current circumstances, we might expect or even predict that two different people would
react differently to the same (precipitating) event.
Perpetuating factors are the factors that are causing the patient's symptoms to continue or progressively
worsen.
Some students find it helpful to use these headings in the formulation. Other students are able to write
more freely without them. Note that most students appear to benefit from structuring the factual
information in the history and mental state using headings.
Management structure
6. Management
On the basis of your formulation, you will need to outline appropriate management plans, including:



Investigations
Short-term goals
Long-term goals
Sample text and writing tips <www.monash.edu.au/lls/llonline/writing/medicine/psychology/7.1.xml>
Management example
Example 15:
The appropriate management for Lucy will really depend on the precise nature of the tumour.
However, it will be crucial to monitor her in hospital and provide symptomatic relief for her headache,
neck pain and depression. A review of her co-existing medical conditions, Grave's disease, lupus, and
hypercholesterolemia, will need to be undertaken. In addition, it will be necessary to provide
counselling and support to help Lucy come to terms with her illness and so prevent the likelihood of
her becoming clinically depressed.
Writing tips:
The future tense is adopted at this stage of the report, as management decisions for the patient are still to
be implemented.
Most lecturers would prefer students to provide more detail, especially of who is doing what. The
expected outcomes described briefly above are a start. Many students will just refer the patient to
counselling without stating why or what the expectations are.
First-year essay
This needs intro text.
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Analysing the question <www.monash.edu.au/lls/llonline/writing/medicine/psychology/essaystructure/1.xml>
Reading and notetaking <www.monash.edu.au/lls/llonline/writing/medicine/psychology/essaystructure/2.xml>
Using the literature <www.monash.edu.au/lls/llonline/writing/medicine/psychology/essaystructure/3.xml>
Essay structure <www.monash.edu.au/lls/llonline/writing/medicine/psychology/essaystructure/4.xml>
Academic language <www.monash.edu.au/lls/llonline/writing/medicine/psychology/essaystructure/5.xml>
Signposting <www.monash.edu.au/lls/llonline/writing/medicine/psychology/essay-structure/6.xml>
Citation <www.monash.edu.au/lls/llonline/writing/medicine/psychology/essay-structure/7.xml>
Tense use in essays <www.monash.edu.au/lls/llonline/writing/medicine/psychology/essaystructure/8.xml>
Revising <www.monash.edu.au/lls/llonline/writing/medicine/psychology/essay-structure/9.xml>
Common sentence level problems
<www.monash.edu.au/lls/llonline/writing/medicine/psychology/essay-structure/10.xml>
Analysing the question
This needs interactivity for the sample questions
What is a critical approach to reading a question task?

Try to distinguish all the individual parts of the topic
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Think about the relationships between the individual pieces of information and ideas
Try to organise the information/ideas into some groupings according to their relationships and
give each group an abstract heading
Try to establish some overall picture of how these groups relate to each other, and of how they
contribute to making a whole picture
Be prepared to change the picture as you do your reading
Some sample questions
Drug use
Is marijuana a dangerous drug? In your essay you may wish to consider:
1. The molecular events through which marijuana acts
2. Changes to the brain and behaviour as a result of marijuana use
3. Medicinal uses of marijuana
Gambling
When it comes to gambling, the odds are generally not stacked in your favour. Despite this, some
people find it very difficult to stop. Consider the relative contribution of classical and operant
conditioning to problem gambling.
Attachment theory
Attachment theory has received considerable research and clinical attention regarding social
development in childhood. More recently, investigators have attempted to transfer the theory from
parent-child to an adult-adult context, particularly in terms of romantic adult relationships. Despite the
expansion of this research, concerns have been expressed regarding the adaptability of the theory.
How relevant is attachment theory to our understanding of adult relationships? What is the
significance of the attachment patterns to functioning in adulthood?
Outline the size-distance invariance hypothesis, and discuss how it can explain both the accurate
perception of the sizes of objects (i.e., size constancy) as well as inaccuracies in the perception of
size (i.e. illusions of size).
What factors would you (or perhaps do psychologists) take into consideration in determining if a test is
a good measure of personality?
The history of psychological science since its beginnings in the 19th century has been one of constant
and straightforward progress. Critically discuss using examples to support your analysis.
Reading and notetaking
this bit needs some intro or explanation text and the table could do with an example
Source (full details)
sample text
Results
Significance
Relevance
Essay structure
Possible structures
This needs text and possibly to be split
Strucure 1
 Theme
 Point A
o
o
 Point B
o
o
presentation
discussion
presentation
discussion
Strucure 2
 Theme
 Point A and point B
o presentation
Strucure 3
 Theme
 Point A and point B
o discussion
If describing experiments...
Give specific examples (what was done, found, concluded) Present statistics. Show how findings led to
conclusions.
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Methodological limitations
What's left unexplained
In reviewing previous work...
You need not describe every study ever done on your problem. Cite only articles pertinent to the specific
issues with which you are dealing; emphasise major conclusions, findings, or relevant methodological
issues and avoid unnecessary detail.
When writing the conclusion ...
The conclusion should include any or all of the following:
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
summary of your stance in response to question
wider implications

limitations of the study, caveats
Academic language
This needs intro and explanation text.
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It also seems possible that perhaps [the] reluctance to delay gratification...
had fostered...
Freud postulated that...
It could be said that...
Winnicott is also relevant in understanding...
It could be theorised that Y...
Signposting
This needs intro and explanation text and possibly some interaction with the examples expanded and the
pertinent bits highlighted.
Advance labelling
Example: First it is important to... before... in the next section
Recapitulation
Example: We have already seen how...
Purpose statements
Example: Before I describe and discuss the family rating scales, it is important to give a brief account of
the theoretical basis from which they were derived
Indications of author's position
Example: With a view to this I have become aware of several areas which are open to question, and I will
discuss some of these below.
Signalling importance
Example: The value of this research lies in its demonstration of the immense difficulties facing...
Citations
This needs intro and explanation text.
Author-prominent citation
Kaplan and Ostler (1982) conclude that the value of medicinal uses of marijuana far outweigh the
disadvantages ascribed to the drug by other studies. For instance, they argue that other studies have
never properly
Information-prominent citation
It has been argued that the value of medicinal uses of marijuana far outweighs the disadvantages
ascribed to the drug by other studies (Kaplan & Ostler, 1982). Kaplan and Ostler (1982) point out that
other studies have never properly...
Tense use in essays
To simplify, tenses are used in the following ways:
The present tense <www.monash.edu.au/lls/llonline/grammar/tense/1.xml> is used for:
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a generalisation
o in overviews, statements of main points etc.
a generally accepted scientific fact
o eg: "This thesis investigates the second approach."
a statement made by you as a writer
o eg: "Non-standard applications are now emerging."
a statement reporting the position of a writer and your support or lack of support for this position
o eg: "He begins by offering a definition..."
The past tense <www.monash.edu.au/lls/llonline/grammar/tense/3.xml> is used to:

report/describe the contents, findings or conclusions of past research. It emphasises the specific
nature of the study.
o eg: "Kendell (3) located the origins of this dispute in the Platonic philosophy of reality
residing in universal ideas ..."
The present perfect tense <www.monash.edu.au/lls/llonline/grammar/tense/2.xml> is used to:
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indicate that research in the area is still continuing
o eg: "Since the 17th century, the dominant tradition in medicine has been the approach
introduced by ..."
generalise about past literature
o eg: "Families have been studied by means of group interview"
present a view using an information prominent citation
o eg: "Studies which have explored Freud's ambivalent attitude towards his Jewishness
include ..."
Revising
Structural aspects
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Introduction (clearly states the topic and how it will be dealt with)
Links between paragraphs / sections (implicit / explicit connectors)
Conclusion (refers to topic, based on evidence provided)
Coverage of your topic
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Have you answered the question?
Have you covered the topic in sufficient depth?
Analysis and Argument
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Have you provided adequate analysis?
Do you demonstrate an independent, original approach?
Is your argument thorough, with evidence and supporting information
Coherence
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Are thought relationships clear?
Are headings clear and concise?
Citations, quotations, paraphrasing
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Are there too many / too few?
Are they all reliable, representative sources?
Are the paraphrases really in your own words?
Referencing information
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Are all sources listed in the bibliography / list of references?
Are all reference details complete?
Are they presented in the required style?
Common sentence level problems
The points need to be expanded.
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Spelling and capitalisation
Subject-Verb agreement
Pronoun reference
Redundant Words
Sentence fragments
Run-on sentences
Articles (a/an/the/zero article)
Tense selection
Parallel structures
Logical connectors (eg: however, although, thus, as a result of, by comparison)
Punctuation
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