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Letter 2

The document is a referral letter from a doctor regarding an 11-year-old patient, Emma Johnson, who is experiencing severe asthma symptoms exacerbated by a viral infection. The patient has a history of asthma and has shown minimal improvement despite treatment, with current symptoms including shortness of breath and wheezing. The doctor requests urgent assessment and admission for the patient due to her deteriorating condition.

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7 views1 page

Letter 2

The document is a referral letter from a doctor regarding an 11-year-old patient, Emma Johnson, who is experiencing severe asthma symptoms exacerbated by a viral infection. The patient has a history of asthma and has shown minimal improvement despite treatment, with current symptoms including shortness of breath and wheezing. The doctor requests urgent assessment and admission for the patient due to her deteriorating condition.

Uploaded by

mujtabajunaid03
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We take content rights seriously. If you suspect this is your content, claim it here.
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Ticket Id: 24110

10/04/2010

Dr B Townsend
Emergency Department
Newtown Children's Hospital

Dear Dr Townsend,
RE: Emma Johnson, aged 11 years old

I am writing to refer this patient who is demonstrating signs and symptoms indicative of severe asthma
(provoked by viral upper respiratory infection) for urgent assessment and admission. Please note, she has a
family history of asthma.

Initially, the patient presented to me on two occasions that begun on 30/11/ 2009 with a complaint of
worsening nocturnal cough, which was exacerbated by exercise. On examination, her chest auscultation
showed faint basal wheezes, and her PEFR was running between 250 and 230 L/min. Therefore, Ventolin
puffer (two puffs) three times daily was prescribed. Six weeks later, her symptoms were slightly improved.
However, her asthma was still unstable. Accordingly, inhaled corticosteroid (two puffs) three times daily
was instituted.

Today, when the patient attended my clinic, she was complaining of worsening shortness of breath,
wheezing (48 hours), fever, runny nose, and anorexia. Furthermore, her examination revealed difficulty in
breathing as she was using her accessory muscles, widespread wheezes, and red throat. In addition, her
PEFR was found to be 140 L/min. Consequently, although Ventolin nebuliser was commenced, she had
minimal relief.

Given the above signs and symptoms, I believe the patient needs prompt evaluation and management.

Thank you for your expert care and kindly feel free to contact me if any more information is required. Comment [teacher1]: . Please

Yours sincerely,
Doctor
Report
Word length 212
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