WRITING : LETTER 3

Information

21/9/2020 Date
Dr. Silver Bullet The name and contact details of
Prospect Medical Center the refering doctor and the practice
22 Prosspect Road -> Optional
Prospect 5086

Dear Dr. Bullet Dear Dr…..

Re: Julia Roberts, The patient’s name and date of birth
D.O.B: 18/05/1975 -> Optional

Situation
Thank you for seeing Ms. Roberts a 45 year-old female with difficulty to control gastro-
oesophageal reflux disease for your consideration of a gastroscopy
Situation: other structures
I am writing to refer Ms. Roberts, a 45 year-old woman for evaluation and consideration for
gastro-esophageal reflux disease
=> Relevant summary of the patient presentation
Situation: other structures
I am writing to refer patient’s name, age, (marital status), for evaluation and consideration
for chief complaint
I would be grateful if you would see patient’s name, age, (marital status)
I would be grateful for your opinion and advice with regard to patient’s name
Thank you for seeing patient’s name for an opinion and suggested management in regard to
her chief complaint
Situation: other structures
I would be grateful if you would see this 45 year-old woman who has been suffering from her
gastro-esophageal reflux disease
I would be grateful for your opnion and advice with regard to Ms. Roberts.
This 45 year-old woman has had 6 months of worsening epigastric pain, worse after meals
Thank you for seeing Ms. Roberts for an opinion and suggested management in regard to
her gastro-esophageal reflux disease
Background
She has had 6 months of worsening epigastric pain. Worse after meals. She has not displayed
any constitutional symptoms during this time. Her medical history includes obesity and a
cholecystectomy in 2016. She is currently on 40mg esomeprazole daily and doesn’t have any
allergies
Background
The only finding on physical examination is epigastric tenderness on palpation of her
abdomen. Her most recent liver function tests (dated 1/3/2020) and upper abdominal
ultrasound (date 1/2/2020) were normal. AH. Pylori breath test (dated 1/3/2020) was
negative. For the past 6 months she has been managed with 40mg esomeprazole daily. She
has also modified her diet and been trying to lose weight
Request
Despite this her symptoms persist and I would greatly appreciate your clinical review and
consideration of a gastroscopy to confirm this diagnosis and ensure no other pathology
contributing to her symptoms
-> Purpose of the referral
Request
I would greatly appreciate your clinical review and consideration of a gastroscopy to
confirm…
It would be greatly appreciate if you could review her and provide a gastroscopy (further
tests)
Closing
Kind Regards
Dr. AH
Closing
For any queries, please do not hesitate to contact me (optional)
Sincerely
Structure of a referral letter:
* Information:
-The name and contact details of the referring doctor and the practice
-The patient’s name and date of birth
* Situation:
-Relevant summary of the patient presentation
* Background:
-Relevant medical history
-Current medications and any allergies
* Assessment:
-Relevant examination and investigation findings
* Request:
-Purpose of the referral
* Closing