Scenario date: 18 June 2018
You are a practitioner examining a 45-year-old female patient, Ms Anne Hall.
Writing Task:
Using the information in the case notes, write a referral to Dr Jason Roberts, gastroenterologist, at Newtown Hospital, 111 High Street, Newtown.
In your answer:
- Expand the relevant notes into complete sentences
- Do not use note form
- Use letter format
The body of the letter should be approximately 180–200 words words.
Patient Details:
| Name: | Anne Hall (Ms) |
| DOB: | 19 Sep 1972 |
| Height: 163cm Weight: 75kg BMI: 28.2 (overweight 18/6/18) |
| Social History: | Teacher (Secondary – History, English); Divorced, 2 children at home (born 2002, 2004); Non-smoker (since children born); Social drinker – mainly spirits |
| Substance Intake: | Nil |
| Allergies: | Codeine; dust mites; sulphur dioxide |
| Family History: | - Mother – hypertension; asthmatic
- Father – peptic ulcer
- Maternal grandmother – died heart attack, aged 80
- Maternal grandfather – died asthma attack
- Paternal grandparents – unknown / died 'old age' 94
|
Previous Medical History:
- Childhood asthma; chickenpox; measles
- 1983 tonsillectomy
- 1990 hepatitis A (whole family infected)
- 1992 sebaceous cyst removed
- 1995 whiplash injury
- 1996 depression (separation from husband); SSRI – fluoxetine 11 months
- 2008 overweight – sought weight reduction
- 2010 URTI (Upper Respiratory Tract Infection)
- 2012 dyspepsia
- 2014 dermatitis; prescribed oral & topical corticosteroids
18 Jun 2018
- Presenting complaint: dysphagia (solids), onset 2 weeks post-viral (?) URTI
- URTI self-medicated with OTC Chinese herbal product – contents unknown
- No relapse/remittent course
- No sensation of lump
- No obvious anxiety
- Concomitant epigastric pain radiating to back, level T12
- Weight loss: 1–2 kg
- Recent increase in coffee consumption
- Takes aspirin occasionally (2–3 times/month); no other NSAIDs
- Provisional diagnosis: gastro-oesophageal reflux +/- stricture
Plan:
- • Refer gastroenterologist for opinion and endoscopy if required
- • ↓ coffee/alcohol intake
- • Cease OTC product
- • Pantoprazole 40mg daily