Birch Consult Letter - Dr. Daisy

Chief Complaint

rc-upload-1756929964511-5.docx

Template

Internal Medicine Consult Letter Patient Information: - Patient Name: [patient_name] - Age: [age] - Sex: [sex] - Date of Birth: [date] - Medical Record Number: [medical_record_number] - Referring Provider: [referring_physician_name] - Primary Care Provider: [primary_care_provider_name] Pregnancy and Obstetrical History: - Pregnancy-Related Cardiovascular Risk Event (PRCV): [prcv_details] - Pre-existing Maternal Cardiovascular Risk Factors: [risk_factors] - Gravida/Term/Preterm/Abortions/Living (GTPAL): [gtpal] - Mode of Delivery: [delivery_mode] - Date of Delivery: [date] - Gestational Age at Delivery: [gestational_age] - Baby Information: Sex: [baby_sex], Age: [baby_age], Birth Weight: [baby_birth_weight] History of Present Illness (HPI): - Clinical Status and Systems Review: [hpi_details] - Breastfeeding Status: [breastfeeding_status] - Contraception Used: [contraception_details] Past Medical History: - [past_medical_history] Surgical History: - [surgical_history] Obstetrical History: - [obstetrical_history] Family History: - [family_history] Social History and Substance Use: - [social_history] Medications: - [medications] Allergies: - [allergies] Physical Examination: - Blood Pressure (Average): [bp_average] - Heart Rate: [heart_rate] - Weight: [weight] - Pre-pregnancy Weight: [pre_pregnancy_weight] - Height: [height] - Waist Circumference: [waist_circumference] - BMI: [bmi] - Additional Findings: [exam_findings] Investigations: - [investigations] Impression and Recommendations: (Include only the issues discussed in the encounter transcript, if not discussed in encounter do not include in final note) 1. Hypertension: - Current Status: [bp_status] - Recommendations: [hypertension_recommendations] (for recommendations use the following information - Target BP <140/90 in non-diabetic patients; <130/80 in diabetic patients: If BP at target and no documented HDP state "Patient’s blood pressure has been very stable and no hypertension-related complications during the pregnancy. Will recommend monitoring blood pressure, as needed, at primary care visits" If BP at target and documented HDP state "According to the latest recommendations, women with prior hypertensive disorder of pregnancy, should be screened for chronic hypertension after 6 months. We discussed the different modalities of blood pressure screening, 24-hr ambulatory BP monitoring, home or office BP measurement" If BP is not at target and no documented HDP, state "Should be screened for chronic hypertension: 24-hr ambulatory BP monitoring, home or office BP measurement" If BP is not at target and documented HDP, include recommendations as discussed in the encounter. ) 2. Dysglycemia: - Glycemia Screening Results: [glycemia_results] - Recommendations: [dysglycemia_recommendations] (for recommendations use the following information - If 2h OGTT and A1C is normal, state "Repeat glycemia screening with A1c annually is recommended or frequency can be individualized based upon the diabetes risk and it can be more frequent, for example every 6 months." If 2h OGTT is diagnostic of pre-diabetes, state "Will need repeat A1c in 6 months and then annually" If 2h OGTT is diagnostic for Type 2 Diabetes include recommendations as discussed in the encounter) 3. Dyslipidemia: - Breastfeeding Status: (yes or no) - LDL Level: [ldl_level] - Recommendations: [dyslipidemia_recommendations] (for recommendations use the following information - if Breastfeeding Status is yes, state "need to repeat lipid profile once off breastfeeding" If Breastfeeding Status is no & LDL <3.5 mmol/L, state 'As we know, targets and screening frequency goals in post pregnancy are not yet established, frequency of repeat screening lipid panel should be individualized based upon cardiovascular risk and patient preferences. Patient’s CVD risk is in intermediate range, at least, considering Pregnancy-related Cardiovascular risk event (s)" If Breastfeeding Status is no & LDL = or >3.5 mmol/L, state "if LDL remains equal or more than 3.5 mmol/L, statin therapy may be considered on an individual basis (incorporating the patient's preferences and reproductive plans) to lower LDL to less than 3.5 mmol/L (preferred), recognizing that the optimal LDL target remains unknown in this group of patients. We will recommend to focus more on healthy behavior modifications and repeating lipid profile in 6 months.") 4. Kidney Disease/Function: - Lab Results: [kidney_lab_results] (for recommendations use the following information - If lab results abnormal, state "Patients with prior HDP and with abnormal kidney tests beyond 6 months (3-12 months) after delivery, will need additional work up" 5. Obesity/Overweight: - BMI Status: [bmi_status] - Recommendations: [obesity_recommendations] (for recommendations use the following information - If BMI not at target, state "We discussed in details dietary changes, goals for diet, exercises: - Suggested make small, manageable changes - Diet: reduce carbs, increase protein, fibres. - Goal is to get to pre-pregnancy weight, at least - Discussed exercises/walking – little things to add - Goal: 150min of moderate exercises per week") 6. Health Behavioral Modifications: - Recommendations: [behavioral_modifications] 7. Smoking/Substance Use: - Status: [smoking_status] - Recommendations: [substance_use_recommendations] 8. Breastfeeding Status: - [breastfeeding_status] 9. Contraception Use: - [contraception_use] 10. Recommendations for Future Pregnancies/ASA Indications: - Maternal Risk Factors: [maternal_risk_factors] - Recommendations: [future_pregnancy_recommendations] (for recommendations use the following information - If maternal risk factors for placental-mediated complications present, state "Should she have another pregnancy, it is recommended that she seeks early attention/prenatal care, repeat blood work, blood pressure check. She will have indications for daily ASA to start at 11-16 weeks GA and continue through until 36 weeks GA. " 11. Mental Health/Mood: - Refer to Family Medicine Consult for Details: [mental_health_details] 12. Other Health Issues/Concerns: - [other_health_issues] 13. Follow-Up Plan: - [follow_up_plan]"