Day 03 Case Notes Analysis (Med)



Read the case notes below and complete the writing task which follows.


You are a practitioner examining a 45-year old female patient, Ms Anne Hall.


Name: Anne Hall (Ms)
DOB: 19.09.72
Height: 163 cm Weight: 75 kg 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
F Mother – hypertension; asthmatic;
Father – peptic ulcer
Maternal grandmother – died heart attack, aged 80
Maternal grandfather – died asthma attack
Paternal grandmother – unknown
Paternal grandfather – died ‘old age’ 94

Childhood asthma; chickenpox; measles
1983 tonsillectomy
1990 hepatitis A (whole family infected)
1992 sebaceous cyst removed
1995 whiplash injury
2006 depression (separation from husband); SSRI – fluoxetine 11/12
2008 overweight – sought weight reduction
2010 URTI (Upper Respiratory Tract Infection)
2012 dyspepsia
2014 dermatitis; prescribed oral & topical corticosteroids

No relapse/remittent course
No sensation of lump No obvious anxiety
Concomitant epigastric pain radiating to back, level T12 Weight loss: 1-2kg
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

Writing Task

Using the information in the case notes, write a letter of referral for further investigation and definitive diagnosis to the gastroenterologist, Dr Jason Roberts, 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.


Date: 25/July/2020 25 July 2020

  1. Do not write the word “Date”
Dr Jason Roberts
Newtown Hospital, 111 High Street, Newtown.
Dr Jason Roberts
Newtown Hospital, 111 High Street, Newtown
Dear Dr Roberts,

Re: Ms Anne Hall, 45 years, DOB: 19/September/1972

Dear Dr Roberts,

Re: Ms Anne Hall, 45 years, DOB: 19/September/1972

The patient, Ms Anne Hall, aged 45 years has dysphagia for solids for the past two weeks. The provisional diagnosis of gastro-oesophageal reflux with/without a stricture is made, but we want to get your expert opinion on further investigations like endoscopy and definitive diagnosis.
  1. Do not use the word “patient / case”
  2. Do not repeat age (It is already provided)
  3. Use “has been made” because it is not a completed action.
  4. Rather than “we want to get your…” use its passive, “but your expert opinion is sought for further…”
The symptoms began following a single episode of URTI for which she self-medicated with over-the-counter Chinese herbal products of unknown contents. […] Dysphagia is accompanied by a concomitant epigastric pain going to the back at T12 level. No lump, however, is felt. She __ observed a recent weight loss of 1-2 kg, although her BMI is 28.2.
  1. Ms Hall developed the symptoms following… (It is better you repeat the name of the patient at the start of each paragraph)
  2. For her, Dysphagia is accompanied…
  3. She has observed
  4. “Although” has no meaning here. You can use “while”. (Although is used to express two opposite facts.
There is a history of increased coffee consumption, with aspirin intake twice or thrice per month. She is an occasional drinker. There are no signs of anxiety, but she was diagnosed with depression in 2006. She had dyspepsia in 2012 and her father has peptic ulcer.
We have started the patient on 40mg pantoprazole with the advice of reduction in coffee and alcohol consumption and no further OTC products usage. For further investigations, for example, endoscopy, in order to make a final diagnosis, we are looking forward to your advice.
Thank you for the cooperation in advance. For future queries, please feel free to contact me on the contact provided.
Yours sincerely,

Now take this Case Notes Analysis and Proceed to Letter Writing

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