Zach Foster OET Letter
Case Notes
You are a doctor at Bayview Medical Clinic. You are referring a 22 year old man who has worsening asthma.
Patient details
Name: Mr Zach Foster
DOB: 25/10/91 (age 22)
Address: 77 Creek Road, Bayview
Medical history:
Asthma, since age 3 – problematic at times, 2 previous hospital admissions (most recent – 3 years ago)
Eczema
Smoker – 4 years, 10-20/day
Allergies: cats, Hay fever
Medications: Ventolin prn, Pulmicort 200 mg one puff
Family history: sister (age 18) – asthma
Social history: Builder, single
Presenting complaint: For last (3 weeks)
SOB – when playing sport
Wheeze & cough – waking Pt at night
Use of Ventolin for symptoms
Treatment record
Subjective:
Preventive inhaler (Pulmicort): compliance unclear; claims to use inhaler some of the time
Burning sensation in lower part of the chest after meals – consistent with gastro-esophageal reflux disease (GORD)
Objective: Chest clear
Peak flow 500 L/min
Abdomen lax & non-tender
Tests: CXR, FBE
Diagnosis: Unstable asthma, possible trigger GORD
Treatment:
Ensure compliance with Pulmicort
Trial of pantoprazole (PPI) for GORD
Discussion about smoking cessation
Review 1/52 (after 1 week)
18.10.14
Review: Still smoking
Non-compliant with Pulmicort – forgets to take it
PPI – effective, nil side effects
Test results:
CXR – clear
FBE – normal
Treatment:
Use pantoprazole for another 7/52 (7 wks) then review
Discussion about Pulmicort missed dosage – take as soon as remember then back to normal. do not double dose
Advice on smoking cessation (eg. nicotine patch, information brochures, support groups etc.)
Continue current management, refer to respiratory specialist for lung function and advice about asthma management
Review appointment 7/52
Writing task
Using the information given in the case notes, write a letter of referral to Dr Williams, a respiratory specialist, for further management of Mr. Foster’s asthma. Address the letter to Dr Tanya Williams, Respiratory Specialist, Bayview Private Hospital, 81 Canyon Road. Bayview
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Sample letter
Dr. Tanya Williams
Respiratory Specialist
Bayview Private Hospital
81 Canyon Road,
Bayview
October 18th, 2014
Dear Dr. Williams,
Re: Mr. Zach Foster, D.O.B. October 25th, 1991
I am writing to refer a 22-year-old man who has multiple risk factors that contribute to the development of recurrent asthmatic attacks. Your assessment of his condition by checking his lung function and recommending medications that might prevent similar attacks in future would be highly appreciated.
Today, Mr. Foster returned to discuss results of a chest X-ray and blood test which were unremarkable. He reported having a relief from reflux symptom after taking PPI; however, he has not adhered to Pulmicort use and continues to smoke. Obviously, he needs a treatment plan like a complete course of pantoprazole regimen, a better strategy to address a missed dosage of Pulmicort, an intensive smoke cessation program and a specialist’s advice on asthma management with pulmonary function measurement. Another review was scheduled after the next 7 weeks.
A week earlier, Mr. Foster presented here complaining of heartburn after meals. He also had a 3 weeks’ history of SOB after playing sport and nocturnal wheezing which led to an increase use of Ventolin. His physical examination and PEFR were completely normal. His symptoms suggested unstable asthma because of ineffective use of Pulmicort, GORD symptoms and his smoking habits. Therefore, a trial of pantoprazole treatment for GORD was initiated. He was also advised to stop smoking. A chest X-ray and FBE were requested with a follow-up in a week period.
Mr. Foster, a builder, has suffered from asthma since age 3 and he required 2 admissions due to the disease the most recent of which was 3 years ago. He has eczema and allergic rhinitis. His current medications are Pulmicort 200mg twice daily and Ventolin as needed. His family history is significant with his sister suffering from asthma. Please note that he is a moderate smoker.
If you have any queries please do not hesitate to contact me.
Yours sincerely,
Doctor
