{"text":"Page 2 of 3 \n\" CLINICAL INFORMATION \nMain \npresenting \nReferral: \nComplaint: . \nReason for Dear Doctor, \nHistory of presenting complaint \/ examination findings \/ investigation results \nPresenting complaint \nRequest to be reappointed for upper GI endoscopy \nMany thanks for reappoihting this 38-year-old lady who has troublesome symptoms of GORD despite \nOmeprazole 20mgs bd. Her main symptom is upper abdominal epigastric pain. She has a history of previous \n_ lron deficiency anaemia and was due to have an endoscopy earller this year to investigate this further \nhowever, unfortunately, she failed to attend. This is her second endoscopy that she has failed to attend due to \nanxiety. I had a long discussion with her today and explained the importance of this and that she must attend. \nShe is currently already taking anti-anxiety medication. She has tried lifestyle measures including eating regular \nmeals and cutting down on alcohol and caffeine intake. She denies any weight loss. As mentioned, she remains \non iron replacement therapy, however, I have updated her FBC and will let you know of any signiflcant results, \nAs you will be aware, she had a significant iron deficlency anaemia requiring transfusion In December 2019 and \ndue to her ongoing symptoms I certainly think she warrants further investigation with upper GI endoscopy and \nshe assures me she will attend. ' \nKind regards. \nYours sincerely, \nDr. Rita Maclnnes \nReason for referral \nCare type requested: Out Patient \nExpected outcome: Not Specified \nPast medical history \nHigh and Medium Priority Pre-existing conditions \nDescription : Laterality ~Modifier Extension\u2019 Date Recorded \nIron deficiency anaemias - New event \/ admitted. 21-Nov-2019 \n{ Body mass index less than 20 - - - \u2018 29-Jul-2008 \nTermination of pregnancy - - medical 22-Apr-2006 \nH\/O: depression .- j - and suicidal ideation 15-Feb-2005 \nDrug addiction - - CODEINE 03-Sep-2002 \nSchool problem - - extreme school avoidance 01-Jan-1995 \nCurrent medication (Active Repeat medication issued within the last 12 morfths) \nDrug name BNF code Formulation Dosage Frequency %%if:\u2014z \nskt copetis T 6o78020 capsule G UASCEEONCEADAY -z \nMirtazapine 45mg tablets 88881020 tablet }WT Q?EEEONCE ADAY | ;gffp' \nE:glr:;s fuwarate 210mg 61843020 tablet \u2019 CD)QE THREE TIMES A N gg;l;ov- \nRecent medication (Any medication issued within fast 90 days not shown above) \nDrug name \u2018 BNF code Formulation . Dosage \u2018Frequency (s:t(;urtr:: \nFenous f\u201cma_\u2019ate 210mg 61843020 tablet 1 THREE TIMES A DAY - o \nCIDTCIIOB G g SOFUENCEADY 2o \nE:t:lftzs fumarate 210mg 61843020 tablet SEE THREE TIMES A } ;g-ll\\;ov- \nfile:\/\/\/N:\/PCTl\/Docman7\/Data S1\/Document\/DMEDOC01\/00003900\/01394784. HTM \nDuratibn \n- Duration 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