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Referral Letter Details

Referral ID: 7f3d7880-6ed2-4aa4-bf12-ea97d7414c00

Created: 2025-07-05T06:51:12.380745

Status: completed

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Referral Letter

Dear Colleague,

I am referring Mrs. Jones to you as she presented with abdominal discomfort for the past two to three months. The discomfort is most noticeable after consuming rich food. She denies weight loss or altered bowel habits; however, she identified occasional loosening of her bowel movements that tend to be slightly paler than usual. She is generally fit and well, but has a history of mild depression for which she takes **citalopram 20 mg daily**.

Of note, this lady has an allergy to **penicillin**. She works as a secretary and has no significant family history of relevance. On physical examination, she appeared fairly well and was of average build. Her vital signs included a temperature of 36.2°C, a blood pressure of 142/67 mmHg, and a pulse rate of 81 bpm. Assessment of her skin, ENT, and lungs were unremarkable. Examination of the abdomen revealed a slightly tympanic abdomen with mild right upper quadrant discomfort.

I arranged for her to have the appropriate investigations, which included a full blood count, inflammatory markers, renal functions, and liver function tests, all of which returned satisfactory outcomes. However, an ultrasound identified two gallbladder stones, which I suspect are the cause of her discomfort.

Therefore, I would be grateful for your assistance.

Yours sincerely,

Audio Transcript

Dear Dr. Smith, I am referring Mrs. Jones to you as she presented with abdominal discomfort for the past two to three months. The discomfort is most noticeable after consuming rich food. She denies weight loss or altered bowel habits. However, she identified occasional loosening of her bowel movement that tend to be slightly paler than usual. She is generally fit and well. However, she has a history of mild depression for which she takes citalopram 20 mg daily. Of note, this lady has allergy to penicillin. She works as a secretary with no significant family history of relevance. On physical examination, she appeared fairly well. She was of an average build and I note her vitals including a temperature of 36.2, a blood pressure of 142 over 67 with a pulse rate of 81. Skin ENT and lungs assessment were unremarkable. Examination of the abdomen identified slightly tympanic abdomen with mild right upper quadrant discomfort. I arranged for her to have the appropriate investigations. These included full blood count, inflammatory markers, renal functions and liver function tests, all of which returned satisfactory outcome. However, an ultrasound identified two gallbladder stones which I suspect are the cause of her discomfort. Therefore, I would be grateful for your assistance.