NOTES:

Susan Forrest is a female patient of yours

Patient:

Susan Forrest

DOB:
19/05/97 (age 24)

Address:
88 Ridge Road, Dandenong East

Social History:
Single, graphic designer
Youngest in family
Social drinker
Smoker - 7 years, 10-15/day

Family History:
Father also has asthma
Mother - hypertension
Younger brother - ADHD
Grandfather - type 2 diabetes

Medical History:
Asthma, since age 4.
Two previous asthma related hospital admissions, most recent 2015
Allergic rhinitis
Eczema
Anxiety disorder
Fractured tibia (2002)

Current Drugs:
Ventolin (albuterol)
Symbicort (budesonide/formoterol) - twice daily
Zyrtec (cetirizine)

12/3/17
Mild food poisoning - diarrhoea
Encouraged electrolytes
Medical certificate written for work

25/8/17
Short of breath - ongoing
Nocturnal cough 7 nights p/w
Ventolin use ↑
2/9/17
Abdomen lax & non-tender
P: 76 bpm
T: 36.5°C
BP: 110/70
CXR: Clear
FBE: Normal
PEF: 400L/min

Notes
Noncompliance with preventive inhaler - “forgets”
Discussed smoking cessation options (nicotine patches, support services)

Treatment Plan
Assess and evaluate
Continue w. current meds.

WRITING TASK:

Using the information given in the case notes, write a referral letter to Pulmonologist, Dr Jan
Walker, at “Epstein Clinic”, 393 Victorian Road, Richmond, Melbourne.

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.

2 September 2017

Dr Jan Walker
Epstein Clinic
393 Victorian Road
Richmond
Melbourne

Dear Dr Walker,

Re: Ms Susan Forrest, DOB: 19.05.1997

Thank you for seeing Ms Susan Forrest, who presents with ongoing shortness of breath,
nocturnal coughing and worsening asthma control, for your assessment and evaluation.

Ms Forrest was first diagnosed with asthma at age four and has been hospitalised on two
occasions with severe exacerbations, most recently in 2015. She is currently prescribed for its
management Symbicort (twice daily), however her compliance with this is variable as she
often “forgets” to take it. Ventolin is also prescribed, for which she reports an increase in its
use, and she also takes Zyrtec. In addition, she smokes 10 -15 cigarettes per day.

On examination today, Ms Forrest’ s chest x-ray and FBE were normal and her peak flow
was 400L/min.

I have reinforced with Ms Forrest the importance of taking her inhibitor regularly and the
need to cease smoking. However, I feel that a more complete management plan is required.

Given her current symptoms and long history of asthma I would be very grateful if you could
please assess and evaluate Ms Forrest’s lung function further in order to provide her with
guidance on how this condition should best be managed. I would also appreciate your opinion
on whether or not she should continue as prescribed with her current medications.

Please contact me if you have any questions.

Yours sincerely,

Doctor