William Jhonson
Dr Fransiska Hutahaean
87 George Town Road
NEWNHAM, TAS 7248
24-08-1992
Dr G Brian
Emergency Department Medical Officer
Alfred Hospital
Commercial Road
PRAHRAN, VIC
Dear Dr Brian,
I am referring Mr. William Johnson, 23 years old, of , Frankston, who has been complaining of abdominal pain for 2 days.
24 Ashwood ST
He first presented yesterday with a 24 hour history of crampy central abdominal pain, nausea and several loose bowel motions. There was a generalized central abdominal tenderness. I assessed him as having the possibility of viral gastroenteritis. I advised him to take more fluid and rest. I prescribed an analgesia[i] and sent him home.
Today he came back again due to worsening abdominal pain. He had vomited several times overnight and could not eat or drink. On examination I found a rise in temperature. He was flushed and restless. There was tenderness with mild guarding in his right abdomen. The bowel sounds were slightly diminished. I started to consider the possibility of early appendicitis. I prescribed Maxolon 10 mg tablet to be taken four hourly while maintaining his fluid balance.
Further investigation has shown that his blood pressure had increased (140/90 mmHg) as well as his temperature ( 38,8°C ). There was localized tenderness in his right iliac fossa with guarding and rebound tenderness. The bowel sounds had diminished. His blood test showed leukocytosis ( white blood cell count was 18.000 cells/mm ) which confirmed my diagnosis:acute appendicitis.
I would be grateful if you could arrange an admission for surgical assessment and urgent appendectomy.
Yours sincerely,
Dr Fransiska Hutahaean
General Practitioner
Probable Grade: A
[i] I prescribed analgesia or
I prescribed an analgesic
Correction by Kay, the corrections are in the bold.
Dr Fransiska Hutahaean
87 George Town Road
NEWNHAM, TAS 7248
24-08-1992
Dr G Brian
Emergency Department Medical Officer
Alfred Hospital
Commercial Road
PRAHRAN, VIC
Dear Dr Brian,
I am referring Mr. William Johnson, 23 years old, of , Frankston, who initially presented on 23/08/1992 with a 24-hour history of crampy abdominal pain, nausea and several bowel motions. I assessed him as having possible viral gastroenteritis. I advised him to increase his fluid intake, bed rest and prescribed an analgesic.
24 Ashwood Street
Today he returned due to a worsening of his condition. He vomited several times last night and he was unable to keep his food down. On examination, his vital signs were within the normal range. There was tenderness with mild guarding in his right abdomen. I started to consider the possibility of early of early appendicitis. I prescribed Maxolon 10 mg tablet to be taken four hourly while I maintained his fluid balance. I also ordered a blood test.
Further investigation has shown that the pain, which was severe and constant, was localized to his right iliac fossa. He was flushed and restless. His blood pressure had increased (140/90 mmHg) as well as his temperature ( 38,8°C ). The tenderness in his right iliac fossa still remained with guarding and rebound tenderness. His bowel sounds had diminished. His blood test revealed leukocytosis ( white blood cell count was 18.000 cells/mm ) which confirmed my diagnosis : acute appendicitis.
I would be grateful if you could arrange an admission for surgical assessment and urgent appendectomy.
Yours sincerely,
Dr Fransiska Hutahaean
General Practitioner
Correction by Andrea
