Speech Pathology · Referral letter · Beginner

OET Case Notes: Speech Pathology Dysphagia Referral (Beginner)

A speech pathologist writes to an ENT surgeon requesting videofluoroscopy for a 58-year-old with two months of progressive solid-food dysphagia. This is a clean beginner referral: one presenting problem, one investigation requested, and clear clinical background. A good starting case for practising concise, purposeful medical letters.

Letter type

Referral

Write to

ENT Surgeon

Target length

180–200 words

The case notes

Patient: Mr Thomas Park, 58 years old

Referral source: GP referral following two months of worsening difficulty swallowing

Presenting complaint: Progressive dysphagia to solids; no difficulty with liquids; occasional coughing after eating

Assessment: Oro-pharyngeal assessment normal; no oral weakness; laryngeal function intact clinically

Dietary modification: Currently IDDSI Level 5 (soft diet); maintaining adequate oral intake

Weight: 3 kg loss over 2 months (82 kg down to 79 kg)

Social history: Non-smoker; social alcohol; employed as school teacher

Clinical impression: Possible pharyngeal-phase dysphagia or structural lesion; clinical assessment insufficient to exclude

Investigation requested: Videofluoroscopy (modified barium swallow) to evaluate pharyngeal phase

Writing task

Write a referral letter to ENT surgeon Dr Sandra Ali requesting a videofluoroscopy for Mr Park, summarising your assessment findings and the reasons for referral.

What to include, what to cut

The hardest mark to win is selection. The same case notes contain decision-relevant facts and distractors. Here is what an examiner expects to see in a Grade B letter for this scenario, and what should be left out.

Include

  • The nature and timeline of the dysphagia (progressive, solids only, 2 months)

    The pattern of dysphagia is the most important diagnostic detail. Progressive solid dysphagia with liquid sparing points toward a structural cause — the ENT surgeon needs this to triage the referral appropriately.

  • Your clinical assessment findings and their limits

    Stating what you ruled out (oral weakness, laryngeal dysfunction) explains why instrumental investigation is needed and gives the surgeon a clinical baseline.

  • The specific investigation requested and why

    Purpose requires clarity. 'Videofluoroscopy to evaluate pharyngeal phase' is more informative than a generic 'further investigation'.

Leave out

  • The patient's pre-illness weight

    Mention the weight loss and current weight — but the pre-illness figure is not clinically necessary for this referral and uses words the word count does not allow.

  • An explanation of IDDSI levels

    ENT surgeons understand dietary modification codes. Explaining Level 5 treats the recipient as uninformed and wastes the letter's register.

Criterion in focus · Purpose

Purpose is assessed in the opening sentences. The examiner should know in the first 25 words who the patient is, what you are asking for, and why. 'I am writing to request videofluoroscopy for Mr Thomas Park, 58, who presents with two months of progressive solid-food dysphagia' earns the Purpose mark. A vague opener such as 'I am writing with regard to the above patient' does not.

Now write the letter — and find out what is blocking your Grade B

Write a 180–200 words referral letter from these notes, paste it into the free checker for an instant read, then submit it for a human grade against all six criteria. Dr Mariam's team returns line-by-line feedback, from $12.

Questions about this case note

Do I need to mention the IDDSI level in a referral to an ENT surgeon?
State the dietary level so the surgeon knows the current functional impact, but do not explain what the level means. They know the system. One line is enough: 'currently IDDSI Level 5 (minced and moist), maintaining adequate oral intake'.
Should I list a differential diagnosis in an OET referral letter?
A brief clinical impression is appropriate — 'possible pharyngeal-phase dysphagia or structural lesion' — but a full formal differential is not. You are requesting investigation, not presenting a case conference.

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