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Discharge Letter - Chest Pain and GERD

Oet writing sample for medicine profession

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19 views3 pages

Discharge Letter - Chest Pain and GERD

Oet writing sample for medicine profession

Uploaded by

Julia
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Discharge letter – chest pain and GERD

*Case note is blurry, but most information are irrelevant, so just refer to the details
written down

Paragraph one – patient, condition, request

Mrs Henning was presented to the Emergency Department today after experiencing chest pain
that might be attributable to gastro-esophageal reflux. Your follow up care is highly appreciated.

Paragraph two

Details: 6/01/2019 – new onset of chest pain 2-3 episodes, “compression” pain only at night,
improved with repositioning (use 2 pillows), recently consuming larger meals at night

Mrs Henning presented with 2-3 bouts of chest pain. She also complained that she felt
“compression” pain on her chest at night, which was relieved by repositioning herself
using two pillows. In addition, she mentioned that she has been eating larger meals at
night recently.

Mrs Henning presented with 2-3 bouts of chest pain. She complained of compression-
like chest pain at night, which can only be alleviated by elevating herself with the help
of two pillows. She also reported that she has been consuming larger meals at night
recently.
Paragraph three

Details: generally thin, vitals such as BP, heart sounds, abdomen sounds are normal

An assessment noted that Mrs Henning is thin. However, her Vitals such as BP, heart sounds,
abdomen sounds are normal

Or we can simply put this information in paragraph 2 saying that: Mrs Henning’s physical
examination was unremarkable

Paragraph four

Details: provisional diagnosis – chest pain resulting from GERD as only when lying down / not
presented with exertion / larger meals at night

Update patient’s GP of recent onset

COPD – continue medications. Follow up with GP in 3-4 weeks.


Chest pain – discontinue eating 2-3 hours prior to sleep, follow up with GP in 3-4 weeks – if chest
pain continues despite meal adjustment – call GP or visit emergency department. If chest pain
begins on trigger – call GP or visit emergency department

My provisional diagnosis of Mrs Henning is chest pain attributable to GERD because her pain is
only present when she is lying down or after she has consumed larger meals at night. As you are
aware that Mrs Henning has COPD, it is recommended for her to continue with her current
medications – albuterol inhalers. Regarding Mrs Henning’s chest pain, it is advisable for her to stop
eating 2-3 hours before sleeping. However, if this chest pain persists or is triggered by exertion,
she should consult you or visit the emergency department immediately.

Mrs Henning’s condition is an indicative of chest pain attributable to GERD because her pain is
only present either when she is lying down or after eating larger meals at night. The fact that pain
doesn’t occur during exertion supports the finding. Since Mrs Henning has COPD, it is
recommended for her to adhere to her current medications. Regarding Mrs Henning’s chest pain, it
is advisable for her to avoid eating 2-3 hours before sleeping. However, if this chest pain persists
or if it is triggered by exertion, she should report it to either yourself or to the emergency
department at once.

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