NEW CASE NOTE - JACK THOMPSON

 Patient Details:

Name: Jack Thompson
Age: 25 years
Occupation: Student at Melbourne University
Social History: Frequently consumes processed and gluten-rich foods due to a busy schedule

Admission Details:
Hospital: Wellington General Hospital
Ward: Gastrointestinal
Admission Date: 05/08/19
Discharge Date: 12/08/19

Presenting Complaints:

  • Chronic diarrhea

  • Abdominal pain

  • Bloating

  • Unintentional weight loss

Examination Findings:

  • Signs of malnutrition

  • Fatigue

  • Irritability

Investigations:

  • Routine blood and urine tests

  • Low hemoglobin (8.2)

  • Vitamin D deficiency

Medical History:

  • Childhood eczema

  • Seasonal allergies

Treatment During Hospital Stay:

  • Intravenous fluids for dehydration

  • Iron supplements

  • Vitamin D supplementation

Discharge Plan:

  • Follow a strict gluten-free diet

  • Consume nutrient-dense, fresh foods

  • Referral to clinical dietician for dietary planning and support

  • Follow-up in two weeks for review

  • Monthly hemoglobin monitoring

Using the case notes provided, write a referral letter to Mr. Sam Paul, Clinical Dietician, Wellington House, 124 Cork Tower, Melbourne.

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