Dr Gerald Jones
24 Sophia Avenue
17 March 2018
Dear Dr Jones
Re: Mr Jeremy Taylor, aged 54
Thank you for seeing Mr Jeremy Taylor, who was diagnosed with stage two A non-small cell lung cancer is being transferred at your facility for ongoing monitoring and appropriate care following the discharge today.
On 5 March 2018, Mr Taylor was presented with complaints of respiratory infection and rust-coloured sputum. Upon examination, mild pyrexia was observed. Tablet Amoxicillin 500mg twice a day was commenced for the five days. After follow-up period, a cough was reported and investigations showed provisional diagnosis. Also, computed tomography scan was conducted which revealed category TIC, NO, MO (2.5 cm tumour) in the left lung. However, bronchial branches were unremarkable.
On 15 March, VATS surgery was performed to remove the tumour successfully, which was carried out through four incisions. Tubes were removed along with the dressing on the site of incision on the subsequent day. Pain was managed with Tablet Percocet and for mild hypertension Tablet Ramipril 5 mg was commenced.
Mr Taylor has habit of cigarettes smoking, often smokes ten cigarettes per day. Despite of use of nicotine and electronic cigarettes, cessation was reported unsuccessful. CT scan review is advised after three months; thereafter annually and chest x-ray thrice a year as well as investigations of complete blood count weekly for next 2 months. The adjuvant chemotherapy treatment record is attached to this letter for your kind perusal.
Based on the aforementioned circumstances, your expert follow-up monitoring and appropriate management of Mr Taylor’s health condition would be profoundly beneficial. In case any additional information is required, please do not hesitate to contact me.
Clare Medical college Hospital
24 Harley Drive