CardiaConsult Letter Template v2 - Dr. Anne Chou

Template

Dear [referring_physician_name], I had the pleasure of reviewing [Patient's Full Name] in follow-up today, a [Patient's Age] year old [Patient's Gender] with [Primary Diagnosis]. Past Medical History: [[Provide a detailed list of past medical conditions and surgical history. Include the following details for each condition or surgery: - Condition or surgery name - Year of diagnosis or surgery - Relevant details such as severity, specific findings, or outcomes - Any related family history or genetic predispositions - Treatments or interventions received, including medications or surgeries - Any notable events or complications related to the condition Organize the section in a bulleted list format, maintaining the order of conditions as presented.] For example: CAD on CCTA 2023, < 25% LM, pLAD, mLAD (adverse features), D1 50-69% dLAD, < 25% oD2, mdLCx, oOM1, mdRCA. CAD-RADS 3 P4 PFO Diabetes -On insulin, diagnosed 2010 Borderline family History of premature CAD -brother and father had MI in their mid 50s. PTSD Electrocuted 2017, negative stress test Osteoarthritis Laparoscopic cholecystectomy 2009 Clavicular fracture with surgery 2001 ] Medications: - [medication_name] [dose] [frequency] - [medication_name] [dose] [frequency] - [medication_name] [dose] [frequency] - [medication_name] [dose] [frequency] Allergies: [List allergy_information if mentioned, or write "No Known Medication Allergies "] History: [Provide a detailed narrative of the patient's medical history since the last visit. Include information about any emergency room visits, consultations with specialists, diagnostic tests performed, and any changes in medication or treatment plans. Mention any symptoms experienced by the patient, their duration, and any resolutions. Include details about any lifestyle or health management advice given, such as target levels for blood pressure or cholesterol, and any referrals made to other specialists. Note any psychological or emotional symptoms and their context. Conclude with the current status of symptoms and any ongoing health concerns.] Physical Examination: [BP [systolic]/[diastolic] HR [heart rate value] bpm, [regular/irregular] [Document the findings of the physical examination, including vital signs and any notable observations.] For example: BP 159/91, regular HR 76 bpm. Chest was clear. No carotid bruits. Normal JVP. Apex was normal. No lift. Normal heart sounds with no murmurs or extra heart sounds. Peripheral pulses were normal and there was no pedal edema. Abdominal examination was normal.] Investigations: [[List all relevant investigations, including labs, imaging, and diagnostic tests, with their findings.] Formatting rules: Investigations from uploaded consult letter = older investigations prefix with -. Investigations from transcript or performed since last consult letter = new investigations list with no dash. Separate each investigation with a blank line. Within each category, sort investigations from oldest to newest. Show older investigations first, then newer investigations.]] Assessment and Plan: 1. [Diagnosis or problem 1 from prior consult note]: [Assessment and management plan for the problem. Include any changes to medications, recommendations for lifestyle modifications, or plans for further investigations.] 2. [Diagnosis or problem 2 from prior consult note]: [Assessment and management plan for the problem.] [Continue as needed for additional diagnoses or problems.] Thank you for involving me. Unless you specify otherwise, I will follow up again in [Follow-up Interval] with a set of labs [and other planned investigations]. cc [List of other physicians or healthcare providers copied on the note