E2 Language Writing

NOTES:

Tom Riddle has been presenting to your clinic with symptoms of asthma.

Patient:
Tom Riddle

DOB:
19/05/98 (age 20)

Address:
88 Ridge Road, Dandenong East

Social History:
Student
Non-smoker
Social drinker
Sports: Indoor football

Family History:
Father - shoulder reconstruction (25/08/2014)
Mother - hypertensive
Grandfather - asthmatic
Younger sister- IgA nephropathy

Medical History:
Childhood asthma - nil episodes 8 years
Eczema (periodic)
No known allergies

1/6/18:
2 wks - breathlessness ‘needs to sit up’
Persistent coughing/wheezing, eyes itching
Missing classes

Notes:
New accommodation-two cats, dusty old carpet, sleeps on floor

2/6/18:
CXR: Clear
Pre-bronchodilator - FEV1: 3.61
Post-bronchodilator - FEV1: 4.35
Response positive - 20%

Diagnosis:
Asthma
Plan:
Oral prednisone 50 mg - 10 days
Albuterol inhaler 2x day
Symbicort (Budesonide/Formoterol)
Advised allergen management
Return 4 weeks or as needed

14/6/18:
Sleep disruption ↑ 7 nights p/w
Albuterol ↑ 5/6 times daily
Eczema flare
T: 37° C (98.7°)
BP: 190/88 mm Hg
P: 122 beats/minute
Respiratory rate: 32 breaths/minute
Oxygen saturation (O2 sat): 88%
ABG: PaO262 mm Hg (below normal range), PaCO2: 42 mm Hg
Auscultation: bilaterally diminished lung sounds
Expiratory wheezing - upper/lower fields.
Administered oxygen 3 L, attained O2 sat 93%
Albuterol hourly, I.V. corticosteroid - Positive response

17/6/18:
Education - discussed environmental triggers, proper inhaler technique
Refer to allergist- allergenic testing, guidance on environmental management

WRITING TASK

Using the information in the case notes, write a letter of referral to Dr Robson, an allergist at
Central Hospital, for testing and identification of Mr Riddle’s allergies. Address the letter to
Dr Ian Robson, Allergist, Central Hospital, Oldtown.

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.

Model answers

17/06/18

Dr Ian Robson Allergist Central Hospital Oldtown

Dear Dr Robson,

Re: Mr Tom Riddle, DOB: 19/05/98

I am writing to refer Mr Riddle into your care, who has moderate persistent bronchial asthma.
He requires further testing and identification of his allergies.

On 01/06/18 Mr Riddle presented with a two-week history of breathlessness associated with

persistent coughing, eye itching and wheezing that resulted in his absence from college.

He had an assessment for his lung function on 2/06/2018 that showed a pre-bronchodilator
FEV1: 3.61 and a post-bronchodilator FEV1: 4.35 with a 20% positive response, which was
treated with a short course of prednisone and inhalers. Twelve days later, he presented again
with an acute exacerbation of bronchial asthma that was treated with oxygen, hourly albuterol
and intravenous corticosteroids. Subsequent to this visit he was educated about possible
environmental triggers and proper inhaler technique.

Please note, his past medical history is significant for childhood asthma with good control
over the last 8 years. He has eczema, but no known allergies. He has recently moved into new
accommodation where he keeps two cats. In addition, he owns a dusty old carpet at home and
sleeps on the floor.

I would appreciate it if you could help with Mr Riddle’s allergenic testing and provide
guidance on environmental management.

If you have any questions please do not hesitate to contact me.

Yours sincerely,

Doctor