Social history: • Quit alcohol 2 months ago • Quit smoking 3 years ago • Lives in a care facility with two other residents.
Allergies: • Nurofen causes stomach ulcers.Current medications: • Mirtazapine 15 mg at night- Aripiprazole 20 mg in the morning
Physical exam: • Chest pain in upper left side, worsens with deep breaths.- No features of chronic liver disease observed Assessment: • Possible Alpha 1-Trypsin Deficiency • Possible costochondritis.
Plan: • Blood test for Alpha 1-Trypsin Deficiency.CTPA. • Repeat liver test, chase hepatitis screening test.
Follow-up in a month.
... Complete letters out
Dear Dr. Tsang,
I am writing to update you on the recent consultation I had with Yiming, a 54 year-old male, who was referred to me for a follow-up regarding acute pyelonephritis and fatty liver disease.
Present Illness He has been experiencing constant chest pain, which worsens with deep breaths. The pain is not relieved by Paracetamol. He has a history of pneumonia, black phlegm, and frequent urination
Medical History Yiming has a medical history of schizophrenia, emphysema, and fatty liver disease.
Social History Hequit alcohol two months ago and stopped smoking three years ago. The patient currently resides in a care facility with two other residents.
Allergies He has reported that Nurofen causes stomach ulcers.
Current Medications • Mirtazapine 15 mg at night • Aripiprazole 20 mg in the morning
Physical Examination Upon examination, the patient reported chest pain in the upper left side, which worsens with deep breaths. No features of chronic liver disease were observed.
Assessment His symptoms suggest a possible Alpha 1-Trypsin Deficiency and costochondritis.
Plan I have ordered a blood test for Alpha 1-Trypsin Deficiency and a CTPA. I will also repeat the liver test and chase the hepatitis screening test. I plan to follow up with [Patient Name] in a month.
I will keep you updated on Yiming's progress.
Please do not hesitate to contact me if you have any questions or concerns.
Yours sincerely, Dr Jason Liu
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