​The medical record entries for this referral are based on a real set of case notes and are given below. Think about what information needs to be included, and if there is anything that is not included in these clinical notes that you would want to have known to make the letter as good as possible.

Clive Oliver Pearson                                                               DOB: 21.6.1952

27 Oak Street                                                               NHS number: 123 456 0000

Woodside

ZZ1 2 WW

Consultations

(Today) You, Lee Medical Practice

Problem: abdominal pain

History: still in pain, getting worse, feeling unwell, feverish, not eating, bowels not open 3 days, restless with the pain, especially at night. No vomiting.

Examination: Looks unwell. Temp 38.3.  Indicates pain located in RIF. Abdo- specific point of tenderness on Mc Burney’s line. Guarding and rebound tenderness RIF. Bowel sounds present.

Comment: for surgical opinion, pt in agreement. Arranged via Care Co-ord Centre. Pt to go straight there, wife will drive.

Note WCC 11.4. neutrophil leucocytosis. ESR 88, CRP 322

(Yesterday) Dr A Assad, Lee Medical Practice

Problem: abdominal pain

History: Came on a few weeks ago. Seen by OOH. Came on again last night, better now. Vague central abdo pain. Bowels stopped working since pain came on.

Examination: abdo soft, vague tenderness lower central abdo.

Comment:? Diagnosis, ?? Diverticular. Check FBC, ESR/CRP and review tomorrow.

PMH

Essential Hypertension

Gastro-oesophageal Reflux – normal endoscopy 2005, H pylori eradication therapy 2005.