**Response to referral letter**
**Referral reason**
Many thanks for the referral of Mr. [insert age] [insert gender]. He was referred due to ongoing abdominal pain and suspected inflammatory bowel disease. He reports experiencing cramping abdominal pain, particularly after meals, along with intermittent diarrhoea and weight loss over the past six months. He is a 45-year-old male.
**Past medical history**
* Irritable bowel syndrome (2018)
**Medications**
* Loperamide 2mg as needed
* Mebeverine 135mg three times daily
**Allergies**
No allergies
**Investigations so far**
* Full blood count (10/10/2024): Within normal limits.
* C-reactive protein (10/10/2024): 12mg/L (elevated)
* Stool sample (10/10/2024): Pending
**Plan**
1. Schedule a colonoscopy and endoscopy to further investigate the cause of his symptoms.
2. Review stool sample results when available.
3. Discuss potential treatment options based on the findings of the investigations.
(Only summarise and reformat the information provided in the transcript, contextual notes or clinical notes. Do not add diagnoses, management plans, or clinical recommendations. Do not generate new clinical content.) (Use bold type for subject headings)
Referral reason
[document the reason for the referral, including the patient's presenting concerns, the context of these concerns, and any relevant background information leading to the decision for referral, include the patient's age and gender] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Begin each letter with "Many thanks for the referral of" )
Past medical history
[document previously made diagnoses using a new line for each diagnosis. Include the year of diagnosis if stated in the transcript] (Only include information if explicitly mentioned in clinical notes, transcript or context section)
Medications
[document medications including doses and frequency] (use a new line for each medication) (Only include information if explicitly mentioned in clinical notes, transcript or context section)
Allergies
[document recorded allergies. If there are no allergies insert the phrase "No allergies"] (Only include information if explicitly mentioned in clinical notes, transcript or context section)
Investigations so far
[document investigations that have occured in the past with dates, include results of the investigations if mentioned] (Only include information if explicitly mentioned in clinical notes, transcript or context section)
Plan
[document the plan] (use a new line for each plan, use numbers to denote each new line in the plan) (Only include information if explicitly mentioned in clinical notes, transcript or context section)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)