# Gold-Standard Reference Letters for Clarke Document Generation Evaluation These three reference letters represent the expected output of Clarke's document generation pipeline for each demo patient. They were written by a medical student following NHS clinical correspondence standards, incorporating content from both the consultation transcript and the FHIR electronic health record. They serve as the ground truth for BLEU and ROUGE-L evaluation of MedGemma 27B's generated output. --- ## Letter 1: Mrs Margaret Thompson — Type 2 Diabetes Mellitus Review Dr Sarah Chen Consultant, General Practice Clarke NHS Trust General Practice Department University Hospital London Dr Andrew Wilson Riverside Medical Practice Date: 18 February 2026 Dear Dr Wilson, Re: Mrs Margaret Thompson, DOB 15/03/1958, NHS No. 943-476-2185 **History of presenting complaint** Mrs Thompson attended for routine review of her type 2 diabetes mellitus. She reported feeling generally well overall but mentioned increasing fatigue in the afternoons and increased thirst over recent weeks. She denied any episodes of hypoglycaemia, polyuria, or unintentional weight loss. She confirmed good adherence to her current medication regimen, taking metformin one gram twice daily with meals and gliclazide forty milligrams once daily in the morning. **Examination findings** Blood pressure was measured at 138/82 mmHg. Body mass index was 31 kg/m². Cardiovascular and respiratory system examinations were unremarkable. Peripheral pulses were palpable bilaterally. Foot examination revealed good sensation and no evidence of peripheral neuropathy, ulceration, or skin breakdown. **Investigation results** Recent laboratory investigations demonstrated an HbA1c of 8.2% (66 mmol/mol), which represents a rise from the previous result of 7.8% (62 mmol/mol) recorded on 01/11/2025. This confirms a deterioration in glycaemic control over the intervening period. Renal function showed an eGFR of 68 mL/min, a decline from 72 mL/min recorded on 01/11/2025, with a creatinine of 98 µmol/L. These results indicate stable but mildly impaired renal function (CKD stage 3a). **Assessment and plan** Mrs Thompson presents with suboptimal glycaemic control, evidenced by the rising HbA1c despite adherence to her current medication regimen. Her symptoms of fatigue and increased thirst are consistent with hyperglycaemia. Given the stable renal function, we have agreed to increase the gliclazide dose from 40 mg once daily to 80 mg once daily to improve glycaemic control. Metformin 1g twice daily will continue unchanged. Lifestyle advice regarding dietary modifications and regular physical activity was reinforced, and Mrs Thompson was encouraged to continue her walking routine. She was counselled on the symptoms of hypoglycaemia — feeling shaky, sweaty, or faint — and advised to consume a fast-acting carbohydrate immediately and contact the surgery should this occur. Repeat blood tests including HbA1c and renal function are requested in three months. We will review the response to the dose adjustment at that time. **Current medications** Metformin 1g twice daily (unchanged) Gliclazide 80 mg once daily in the morning (increased from 40 mg) Lisinopril 10 mg once daily Atorvastatin 20 mg once nightly Warm regards, Dr Sarah Chen Consultant, General Practice --- ## Letter 2: Mr Emeka Okafor — Chest Pain Follow-Up Dr Sarah Chen Consultant, General Practice Clarke NHS Trust General Practice Department University Hospital London Dr Andrew Wilson Riverside Medical Practice Date: 18 February 2026 Dear Dr Wilson, Re: Mr Emeka Okafor, DOB 22/11/1971, NHS No. 401-592-7384 **History of presenting complaint** Mr Okafor attended for follow-up review of his recent presentation with chest pain. He had been admitted to hospital for investigation of acute chest discomfort and was discharged following completion of cardiac workup. He reports that the chest pain has not recurred since discharge, though he remains understandably anxious about the symptoms. He denied any breathlessness, palpitations, or syncope. He has been taking his prescribed medications as directed. **Examination findings** Blood pressure was measured at 148/92 mmHg, which remains above target. Cardiovascular examination revealed normal heart sounds with no murmurs, rubs, or gallops. Chest was clear to auscultation bilaterally. There was no peripheral oedema. Body habitus was satisfactory. **Investigation results** Coronary angiography performed on 18/01/2026 demonstrated normal coronary arteries with no evidence of obstructive disease. This is a reassuring finding. Hospital blood tests including high-sensitivity troponin I were measured at 8 ng/L on 20/01/2026, which is within the normal range and below the diagnostic threshold for myocardial infarction. Together, these results effectively exclude an acute coronary syndrome as the cause of his chest pain. **Assessment and plan** Mr Okafor has a background of angina pectoris and hypertensive disorder. The recent cardiac investigations are reassuring, demonstrating no obstructive coronary artery disease and a normal troponin. We discussed how chest discomfort can still occur from non-cardiac causes, including musculoskeletal chest wall strain, gastro-oesophageal reflux, and anxiety. He was reassured that there is no evidence of a heart attack from this episode. His blood pressure remains suboptimally controlled at 148/92 mmHg. We discussed blood pressure management in detail, including reducing dietary salt intake, improving sleep hygiene, maintaining regular physical exercise, and monitoring blood pressure readings at home. Current medications were reviewed and are to continue unchanged at present. If home blood pressure readings remain consistently elevated, we will consider the addition of a further antihypertensive agent. He was advised to seek urgent medical attention immediately if he experiences chest pain that is severe, prolonged, or associated with breathlessness, diaphoresis, or radiation to the arm or jaw. We will review his blood pressure trend and symptoms at his next routine follow-up appointment in eight weeks. **Current medications** Aspirin 75 mg once daily Atorvastatin 40 mg once nightly Warm regards, Dr Sarah Chen Consultant, General Practice --- ## Letter 3: Ms Priya Patel — Asthma Review Dr Sarah Chen Consultant, General Practice Clarke NHS Trust General Practice Department University Hospital London Dr Andrew Wilson Riverside Medical Practice Date: 18 February 2026 Dear Dr Wilson, Re: Ms Priya Patel, DOB 14/07/1993, NHS No. 628-114-7390 **History of presenting complaint** Ms Patel attended for a routine asthma review. She reports using her salbutamol reliever inhaler approximately four to five times per week, which is above the threshold indicating well-controlled asthma (fewer than three uses per week). She has not experienced any acute exacerbations, hospital admissions, or courses of oral corticosteroids in the past twelve months. She denied any nocturnal symptoms, exercise limitation, or occupational triggers. She is not currently using a regular preventer inhaler. **Examination findings** Peak expiratory flow rate was measured at 320 litres per minute, which corresponds to approximately 80% of her predicted best. This indicates mild airflow limitation with room for improvement. Respiratory examination revealed good air entry bilaterally with no wheeze or crackles on auscultation. Oxygen saturations were satisfactory on room air. Inhaler technique was assessed: it was noted that Ms Patel was not holding her breath for a sufficient duration after inhalation, which would reduce drug deposition in the lower airways. Correct technique was demonstrated and she was asked to practise at home. **Investigation results** No additional investigations were performed at this visit. Peak flow monitoring has been requested (see plan below). **Assessment and plan** Ms Patel has asthma that is not optimally controlled, as evidenced by frequent reliever use (four to five times weekly) and a peak flow at 80% of predicted. The suboptimal inhaler technique identified today is likely contributing to reduced medication efficacy. We have agreed to initiate a regular preventer inhaler: beclomethasone dipropionate 200 micrograms twice daily via metered-dose inhaler. Ms Patel was counselled on the importance of using this medication every day, even when asymptomatic, as the anti-inflammatory effect is cumulative and preventive. She was advised to rinse her mouth with water after each use to reduce the risk of oral candidiasis. She has been asked to keep a peak flow diary for the next four weeks, recording morning and evening readings, and to bring this to her next appointment. She was advised to return sooner if her symptoms worsen or if she is using her salbutamol reliever more than three times per week despite regular use of the preventer. We will review her symptom control, peak flow diary, and inhaler technique at a follow-up appointment in six weeks. **Current medications** Salbutamol 100 mcg inhaler, two puffs as required for symptom relief Beclomethasone dipropionate 200 mcg inhaler, one puff twice daily (newly initiated) Warm regards, Dr Sarah Chen Consultant, General Practice