FU Consult Letter Template

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 prior investigations from consult note] (prior investigations are listed on separate lines preceded with dash "-".) [List all relevant investigations, including lab results, imaging studies, and other diagnostic tests, along with their findings.] (each investigation separated by a blank line with no preceding dash "-".) [New Results] For Example: -Labs June 9, 2023: Normal CBC, K 3.6. FBG 8.0, A1 c 9.3%, TC 3.25, LDL 1.32, HDL 1.24, non HDL 2.01, TG 1.52. Normal ALT -Labs January 9, 2023: WBC 11.9, K 3.9, creatinine 64, GFR 106. Negative troponin x2 -Labs September 9, 2022: FBG 6.0, A1 c 7.6%, TC 4.39, LDL 2.36, HDL 1.15, non HDL 3.24, TG 1.93 -Echocardiogram November 22, 2017: Technically difficult. Normal biatrial and biventricular size and function Normal valves. -Chest x-ray January 9, 2023: Normal other than prior plate and screw fixation of the right clavicle. -CCTA January 11, 2023: Right dominant. No anomalies. < 25% LM, pLAD, mLAD (adverse features), D1 50-69% dLAD, < 25% oD2, mdLCx, oOM1, mdRCA. CAD-RADS 3 P4. PFO; otherwise, normal cardiac structures. Incidental 1.2 cm mildly enlarged subcarinal node, likely reactive -Echocardiogram March 24, 2023: Technically difficult; suboptimal. Normal LV size and function, EF 54% with sigmoid septum 12 mm, diastolic dysfunction. Normal RV size, mildly depressed function. No significant valvular abnormality abnormalities. PASP could not be calculated. Normal RAP. Labs March 27, 2024: Normal CBC, K 3.5, creatinine 75, GFR 99. TC 2.81, LDL 1.17, HDL 1.04, non-HDL 1.77, TG 1.32. Negative troponin. Normal lactate Labs March 15, 2024: FBG 10.2, A1c 6.7% Holter May 7, 2024: SR 66-82- 124 bpm. Rare PACs, single ventricular couplet. No pauses/ST changes/diary Echocardiogram July 3, 2024: BP 168/89. Normal biventricular size and function, EF 55%. No significant valvular abnormalities. Normal RAP. No intracardiac source of embolus detected. ECG today showed normal sinus rhythm at 76 bpm with no ST / T changes] 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]