Patient’s Data​

Patient’s name: Sophie Johnson

Age: 10-year-old female

Past medical history

• No known medical conditions

Drug and Allergy History 

• Not currently on any regular medications
• No known drug allergy 

Recent Notes/Consultation 

Seen 3 months ago by Dr Temitope Alao (Clinical practitioner access role) 

Presenting complaint: Patient was seen with mum. She reports intermittent abdominal pain on/off for 2-3 months duration. No change in bowel habits or PR bleeding. No vomiting or diarrhoea, No weight loss 

Examination: Abdomen soft, and non-tender. No masses 

Plan: Bloods including TFTs, LFTs, FBC, U+E’s, Ferritin, Coeliac screen and stool for calprotectin. Review in 2 weeks. 

Investigation Outcome:

Blood and stool calprotectin results were reviewed and found to be within normal limits. Results were filed by Dr Temitope Alao.

Recent A&E Attendance (4 days ago):

Accident and Emergency Letter

To: GP Practice,
Re: Sophie Johnson (Age:10 years old female)

Dear Colleague,

Sophie Johnson, a 10-year-old female, was seen in the Emergency Department today for episodic abdominal pain. She reported recurrent episodes of cramping abdominal pain over the last 6 months which suddenly got worse a day ago and hence presentation to emergency department. There are no associated vomiting, diarrhoea, or fever. On review, she was otherwise well, with no signs of acute illness.

Investigations:

Urinalysis: Normal

Blood Tests (Including, thyroid function test, FBC, U+ E’s, LFTs, Ferritin, Folate, CRP ) : Normal

Bed side ultrasound of abdomen: Normal 

Based on her clinical presentation and the normal findings of the investigations, we suspect abdominal migraine as the most likely diagnosis. 

Recommendations:
If the symptoms reoccur, we recommend that Sophie follow up with her GP for further evaluation and management. Should her symptoms change in nature or become more severe, or if any other concerning symptoms arise, we advise immediate re-assessment.

Kind regards,
Dr Chika Cubana, MBBS FRCEM
ST6 Emergency Medicine Specialist Registrar

Patient’s mum – Emily Johnson has booked routine telephone consultation to discuss ongoing concerns.