FSP Arztbrief 03: Akute Cholezystitis

Sample Doctor’s Letter (Case 03: Acute Cholecystitis – Sabine Krüger, 52 years) – a complete example of an FSP-style medical letter for right upper quadrant abdominal pain. It demonstrates a structured sequence from salutation and introduction through acute history (postprandial onset after breakfast, initial colicky pain evolving to constant pain, radiation to right shoulder/back, worsening with movement, similar episodes after fatty meals), vegetative symptoms (fever, reduced general condition, poor intake), past medical history/medication/allergies (hypertension, obesity; penicillin allergy), social and family history, and a clear summary/assessment (suspected acute cholecystitis; differentials include cholelithiasis and pancreatitis).

Recommended next steps include physical exam (Murphy sign), timely abdominal ultrasound, laboratory workup (CRP/leukocytes, cholestasis parameters, lipase), fasting/IV fluids, analgesia, antibiotic therapy with allergy caution, and surgical consultation for cholecystectomy, ending with professional handover/closing.