Dr Jason Roberts
111 High Street
Dear Dr Roberts
Re: Ms Anne Hall, DOB: 19 September 1965
I am referring Ms Hall who has a provisional diagnosis of gastro oesophagal reflux with possible stricture and requires your further investigation in order to confirm the definitive diagnosis.
Ms Hall has onset upper respiratory tract infection two weeks ago and dysphagia from solids food.she self medicated with over the counter Chinese herbal product, which are unknown contents. She has no obvious anxiety and sensation of lumb. She has epigastric pain which is radiating to back level T 12, and has lost 1-2 kg weight and current BMI is 28.2 .
Ms Hall has recently increased coffee consumption and takes aspirin occasionally 2 to 3 times a month. She has had mild depression in 1998 which is well controlled with medication. She has had dysphagia in 2004 and Ms Hall has been taking oral and topical corticosteroids for dermatitis since 2006.
Given the above, it would be greatly appreciated if you could do further investigation and endoscopy if required and treat as appropriate.
Should you require further information, please contact me .