Cardiology Consult

OVERALL_INSTRUCTIONS

Chief Complaint

Cardiology Consultation Note

Template

Dear Dr. [Referring Clinician Name or family physician's name, never Dr. Ken Gin], Thank you for referring [Patient Name] for evaluation of [his/her/their] [Specific Cardiac Symptoms or Condition]. Cardiac Risk Factors: [Include the following where relevant: - Hypertension - Obstructive Sleep Apnea [adherence to CPAP] - Diabetes: [Control Status, Recent A1c if available] - Dyslipidemia: [Date and result of most recent LDL, non-HDL, Triglycerides. Treatment if mentioned] - Smoking: [Current, Former, Never, Pack Years if applicable] - [For women include relevant pregnancy history if applicable including the adverse pregnancy outcomes if they are mentioned: gestational diabetes, prematurity, hypertension during pregnancy, pre-eclampsia, premature menopause, etc]] Cardiac Diagnoses: [list cardiology diagnoses; include the following where relevant - Atrial Fibrillation [CHADS65 score, paroxysmal vs persistent vs permanent, if explicitly stated indicate rate or rhythm control status. State which anticoagulant they are on.] - Heart Failure [reduced, non-reduced, or recovered. List LVEF % (date of echo). NYHA class [I-IV] if stated.] - Coronary Artery Disease [Date of NSTEMI / STEMI, interventions and on which vessels. Indicate drug or bare metal stent if appropriate, last angiogram results & date] Other Medical History: - [Other PMH in point form using bullet points. Do not include diagnoses in the cardiac diagnoses and cardiac risk factors sections. Include year of diagnosis, physician following them, and relevant qualifiers where appropriate] History of Present Illness: [Patient’s First Name] is a [Age]-year-old [Sex], reports [Detailed Chronological Account of Cardiac Symptoms Progression and Response to Previous Interventions]. [If seeing for heart failure, explicitly state if there has been orthopnea, PND, pedal edema with timeline of symptoms]. Medications: [State how the list was obtained e.g., Medications were reviewed via Pharmanet and confirmed verbally by the patient. Preferentially use the last known cardiology clinic note as the source of medications.] - [Drug Name] [Dosage], [Frequency] - [Drug Name] [Dosage], [Frequency] - [Drug Name] [Dosage], [Frequency] - [OTC/Homeopathic Products if applicable.] Allergies: - [Allergen/Medication]: [Reaction Type/Severity] - [Medication]: [Adverse Effect] (Not a true allergy) Family History: [Relevant Family Cardiovascular Disease History] Social History: [Social History if mentioned, i.e., occupation, living situation, substance use, smoking status, exercise (minutes / week)] Physical Examination: Weight if indicated (kg). BP [Value] mmHg. HR [Value] bpm. RR [Respiratory rate value], on [room air]. SPO2 level if indicated. Comment on general appearance (No acute distress, appears stated age). Precordial exam reveals [Normal S1, S2, otherwise state heart sounds as indicated]. [No appreciable extra heart sounds, rubs, or murmurs, unless otherwise indicated]. JVP [2 cm ASA, or otherwise indicated]. Lungs are [clear throughout, or otherwise indicated]. Peripheral pulses strong and equal bilaterally [or indicate otherwise]. Cap refill <2 seconds [or indicate otherwise]. No peripheral edema [or indicate otherwise]. Investigations: [Include mandatory investigations. Group labs by date, for example: [Date (e.g., Feb 24, 2025)]: WBC, Hb, Plt K, Na Cr, GFR, CrCl Troponin, NT-proBNP TSH if there is a history of atrial fibrillation Ferritin if there is a history of heart failure Include lipid panel as mandatory, for example: [Date (e.g., March 12, 2025)]: Total Cholesterol, LDL, non-HDL, Triglycerides If no lipid panel is stated, indicate 'No previous lipid panel on file.' Include HbA1C] ECG: [Date of ECG] - [Findings of ECG, leave section blank if no ECG indicated] Holter: [Date of Holter ] - [Duration] - [Findings on holter. Delete this Holter section if no holter results are indicated. ] Imaging: - Echocardiogram ([Month Year]): [Findings] - Cardiac CT ([Month Year]): [Findings] - MIBI scan ([Month Year]): [Findings] - Other relevant imaging ([Month Year]): [Findings] Impression: In summary, this is a pleasant [age, gender] with cardiac risk factors of [list briefly cardiac risk factors] and history of [relevant cardiac diagnoses] who was seen today in clinic for assessment of [today's cardiology issues]. Recommendations: 1. [Primary Cardiac Diagnosis]: - [Medication Changes] - [Lifestyle Recommendations] - [Additional Testing Needed] 2. [Secondary Diagnosis] - [Medication Changes] - [Lifestyle Recommendations] - [Additional Testing Needed] 3. [Additional Problems as Needed] Follow-up: We will see [Patient First Name] again in [Timeframe] [in person / telehealth]. Yours sincerely, Dr. Liz Minaker, PGY4 Cardiology On behalf of Dr. [Preceptor].