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/lls/llonline/lls/llonline/writing/medicine/health-sciences/index.xml> , reflective writing
<www.monash.edu/lls/llonline/lls/llonline/writing/medicine/reflective/index.xml> or writing in Psychological
Medicine <www.monash.edu/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/lls/llonline/writing/medicine/healthsciences/1.xml> . Ask yourself whether the case report could be improved in any way.
Next, read Annabelle's annotated assignment
<www.monash.edu/lls/llonline/writing/medicine/health-sciences/2.xml> with comments
from her lecturer. Finally, you can read additional comments
<www.monash.edu/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 longterm 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 hot-blooded, 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 longterm 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 hot-blooded, 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:



[32]
(i) general medical journals
(ii) specialist medical journals
(iii) textbooks
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/lls/llonline/writing/medicine/reflective/1.xml>
and the term critical incident <www.monash.edu/lls/llonline/writing/medicine/reflective/2.xml> , and helps you
explore the reflective learning process <www.monash.edu/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/lls/llonline/writing/medicine/reflective/4.xml> , a sample piece of
student writing <www.monash.edu/lls/llonline/writing/medicine/reflective/5.xml> , criteria for assessment
<www.monash.edu/lls/llonline/writing/medicine/reflective/6.xml> and suggestions to help avoid some
common errors in reflective writing <www.monash.edu/lls/llonline/writing/medicine/reflective/7.xml> .
The section on characteristics of reflective writing
<www.monash.edu/lls/llonline/writing/medicine/reflective/8.xml> covers language features like



tenses <www.monash.edu/lls/llonline/writing/medicine/reflective/8.1.xml>
speculative and hypothetical writing
<www.monash.edu/lls/llonline/writing/medicine/reflective/8.2.xml>
the language of self-reflection vs criticism
<www.monash.edu/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. This was made more
difficult because she was significantly overweight 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
During the second week of my clinical study, I
very difficult to produce an adequate x-ray.
met a patient who needed an x-ray for her
knee and hip joint. She was overweight and
It could be useful to analyse this incident
not very aware of my role as radiographer –
further – for example:
she treated me more like a technician than a
future doctor. Even worse, she was not
What surprised me most about this incident
cooperative, kept murmuring and shouted out
was the attitude of the patient to the health
about her pain throughout the procedure.
professionals. In my culture most people treat
Furthermore, this patient didn't listen to our
health professionals with great respect, and
instructions and wouldn't stay still after
acknowledge their authority; they are even
positioning.
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.
2.
Characteristics of reflective writing
This section covers the language features of reflective writing:



tenses <www.monash.edu/lls/llonline/writing/medicine/reflective/8.1.xml>
speculative and hypothetical writing
<www.monash.edu/lls/llonline/writing/medicine/reflective/8.2.xml>
the language of self-reflection vs criticism
<www.monash.edu/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
When the doctor raised his voice to the
though the doctor was obviously frustrated at the patient's
patient I felt embarrassed. It reminded
apparent inability to understand the instructions. While it is the
me to maintain an appropriate
responsibility of every doctor to behave respectfully with
communication style with patients when I patients, on this occasion an excessive workload and the lack
am a doctor.
of availability of an interpreter no 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/lls/llonline/writing/medicine/psychology/2.xml>
2.
3.
4.
5.
6.
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
Mental State Examination <www.monash.edu/lls/llonline/writing/medicine/psychology/3.xml>
Physical Examination <www.monash.edu/lls/llonline/writing/medicine/psychology/4.xml>
Summary and Diagnosis <www.monash.edu/lls/llonline/writing/medicine/psychology/5.xml>
Formulation <www.monash.edu/lls/llonline/writing/medicine/psychology/6.xml>
Management <www.monash.edu/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/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/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/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/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
Cognition
Judgement
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Insight
Rapport
Sample text and writing tips <www.monash.edu/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/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/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/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/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/lls/llonline/writing/medicine/psychology/essaystructure/1.xml>
Reading and notetaking <www.monash.edu/lls/llonline/writing/medicine/psychology/essaystructure/2.xml>
Using the literature <www.monash.edu/lls/llonline/writing/medicine/psychology/essaystructure/3.xml>
Essay structure <www.monash.edu/lls/llonline/writing/medicine/psychology/essay-structure/4.xml>
Academic language <www.monash.edu/lls/llonline/writing/medicine/psychology/essaystructure/5.xml>
Signposting <www.monash.edu/lls/llonline/writing/medicine/psychology/essay-structure/6.xml>
Citation <www.monash.edu/lls/llonline/writing/medicine/psychology/essay-structure/7.xml>
Tense use in essays <www.monash.edu/lls/llonline/writing/medicine/psychology/essaystructure/8.xml>
Revising <www.monash.edu/lls/llonline/writing/medicine/psychology/essay-structure/9.xml>
Common sentence level problems <www.monash.edu/lls/llonline/writing/medicine/psychology/essaystructure/10.xml>
Analysing the question
This needs interactivity for the sample questions
What is a critical approach to reading a question task?
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Try to distinguish all the individual parts of the topic
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/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/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/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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