Dr Jason Roberts

Gastroenterologist

Newtown Hospital

111 High Street

Newtown

18 June 2018

Dear Dr Roberts

Re: Ms Anne Hall, DOB: 19 September 1972

Thank u for seeing Ms Anne Hall, a 45 year old female, who needs further investigation and definitive
diagnosis for her gastrointestinal symptoms.

On 18 June 2018, she presented with a two week history of dysphagia especially to solids. It was
preceded by a viral URTI, for which she took an OTC Chinese herbal product which cured the infection.
She also experienced epigastric pain radiating to back along with some weight loss. Please note that she
recently increased her caffeine consumption. Moreover, she often takes aspirin. A provisional diagnosis
of esophageal stricture secondary to GERD was made. I prescribed pantoprazole 40 mg daily and advised
her to decrease the coffee and alcohol intake in addition to stopping the OTC, but she required your
expert opinion and endoscopy for her symptoms.

Ms Anne Hall, a teacher by profession is divorced and lives with her two children. Moreover, she is a
social drinker. She is overweight with a BMI of 28.In addition, she has a past history of dyspepsia and
corticosteroid use for dermatitis.

In the light of above mentioned information, it would be highly appreciated if u further investigate her
symptoms and provide a definitive diagnosis.

In case of any queries, feel free to contact me.

Yours sincerely

Doctor