Dyslipidemia

Chief Complaint

Assessment of dyslipidemia

Template

Dear Dr. [Last Name], Thank you for referring [name], a [age] year old [gender], who was seen on [date] for assessment of dyslipidemia. Consent: I obtained consent from the patient for use of an AI scribe software. I explained that Empathia saves a copy of our conversation on their website for the purpose of generating a note, and that this software is FDA approved. HISTORY OF PRESENTING ILLNESS: CAD: [present or absent] CVD: [present or absent] Lipid medications tried: [Insert details] Medical history: [medical_history] Medications: [drug_name] Allergies: [allergies] SOCIAL HISTORY: Exercise: [exercise] Meals: [meals] Work: [work] Extended coverage: [coverage] Alcohol: [alcohol] Cigarettes: [cigarettes] Drugs: [drugs] FAMILY HISTORY: [family_history] EXAM: [general exam, weight, height, vitals, cardiac exam, pulmonary exam] Xanthomas: [present or absent] Xanthelasmas: [present or absent] Corneal arcus: [present or absent] INVESTIGATIONS: [investigations] IMPRESSION AND PLAN: 1. Dyslipidemia: [definite or probably or possible or unlikely] familial hypercholesterolemia, [at target or not at target] of LDL <2 or nonHDL <2.6 - (List recommendations in first person, using language such as "I have...") - I have ordered [an Lp(a) and/or coronary artery calcium and/or carotid ultrasound] to further risk stratify 2. Genetic testing - 3. Follow-up - I have arranged for follow-up [after above investigations or in certain months] PATIENT COUNSELING: I counseled the patient on sick day management for their diabetes medications. I recommended holding metformin and SGLT2-i if feeling unwell or if febrile, and to restart once feeling back to normal. Thank you for involving me in the care of this pleasant patient. Please do not hesitate to contact me with any questions or concerns. Sincerely, Dr. Leo Hu, MD, FRCPC Elida Medical Centre