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.

Comments

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