Dear Dr. Smith,
Thank you for referring Emily Johnson, a 32-year-old, for dietary assessment and management of coeliac disease.
Emily describes experiencing frequent abdominal pain, bloating, and diarrhea, which prompted her visit. I note her investigations to date have shown positive serology for coeliac disease and villous atrophy on gastroscopy.
Medical History: No significant past medical history.
Medications: None.
Anthropometry: BMI 22.5 kg/m².
Emily has adopted a gluten-free diet for the last 3 months. A diet assessment today identified traces of gluten in Emily's diet, likely due to cross-contamination.
Therefore, in today's consultation, I have provided education on a strict gluten-free diet as treatment for coeliac disease. We discussed gluten-free alternatives and food products, label reading to identify gluten-containing or gluten-free products, and strategies to minimize cross-contamination during meal preparation or when dining out. Nutrition resources including suggested meal ideas, a shopping guide, recipes, and gluten-free cookbooks have been provided to assist with long-term compliance. I have encouraged membership with Coeliac Australia to keep abreast with the ever-changing nutrition information.
Finally, we briefly discussed optimizing nutritional adequacy, particularly for iron and calcium, by incorporating fortified foods and supplements. A multi-vitamin and calcium supplement has been recommended.
Emily will return for a follow-up appointment in 6 weeks for further dietary modifications. We may also consider additional nutritional strategies. I look forward to working closely with you. Please do not hesitate to contact me if you require any further information.
Yours sincerely,
Dr. Thomas Kelly