Case Notes:

Patient: Ms. Rebecca Wilson

Date of Birth: 12/04/1990 (34 years old)

Admission Date: 15/12/2024

Reason for Referral: Uncontrolled asthma symptoms despite regular medication

Medical History:

• Recently diagnosed with asthma (2 months ago)
• Allergic rhinitis (diagnosed 5 years ago)
• No known drug allergies
• Mild eczema (childhood, resolved)
• Occasional migraines (treated with over-the-counter analgesics)

Social History:

• Lives with her partner in an apartment in the city
• Works as a graphic designer
• Non-smoker, no alcohol consumption
• Regular exercise, enjoys yoga and walking
• Family history of asthma (mother) and cardiovascular disease (father)
• Recent travel: Returned from a work trip overseas 3 weeks ago

Current Symptoms:

• Persistent shortness of breath, especially at night
• Frequent wheezing, worsened by cold air and physical activity
• Coughing spells, particularly in the morning
• Chest tightness, exacerbated during stressful periods
• Wakes up 2-3 times per week due to breathing difficulties

Investigations:

• Spirometry: FEV1 at 70% of predicted value, indicating moderate airflow obstruction
• Peak flow monitoring: Variability of more than 20% throughout the day
• Allergy testing: Positive for dust mites and pollen
• Chest X-ray: No abnormalities detected
• Blood tests: Normal CBC and IgE levels

Current Medications:

• Salbutamol inhaler 100 mcg PRN (used 3-4 times daily)
• Fluticasone inhaler 125 mcg twice daily
• Loratadine 10 mg daily (for allergic rhinitis)
• Saline nasal spray PRN

Treatment Provided:

• Education on proper inhaler technique
• Advised to avoid known allergens (dust mites, pollen)
• Recommended use of air purifier at home
• Initiated daily peak flow monitoring

Reason for Referral:

• Persistent and uncontrolled symptoms despite regular use of a high-dose inhaled corticosteroid and frequent use of a short-acting bronchodilator
• Possible consideration for additional or alternative therapy, including a long-acting bronchodilator or leukotriene receptor antagonist
• Assessment for potential triggers or underlying conditions exacerbating asthma symptoms

Writing Task:

Using the information in the case notes, write a referral letter to the pulmonologist, Dr. Michael Evans, at City Pulmonary Clinic, 456 Maple Avenue, Metropolis, requesting further evaluation and management of Ms. Wilson’s asthma.

In your answer:

• Expand the relevant notes into complete sentences
• Do not use note form
• Use letter format

The body of the letter should be approximately 180–200 words.