General Consult Letter Template

Chief Complaint

Patient Referral for Chronic Leg Swelling

Template

Dear Dr. [Referring Physician's Last Name], [Thank you for the kind referral of this patient. [Patient pronoun] was referred for [chief complaint]. [Provide a detailed narrative summary of the patient's history related to the chief complaint, including onset, progression, and any relevant treatments or interventions tried previously.] [Detail any medications that were started or stopped and their effects on the symptoms. Include any past medical history relevant to the current condition, such as previous episodes of similar symptoms or related conditions. ] [Note any current treatments or interventions the patient is using, such as compression garments, and any challenges faced in using them. Mention any relevant negative findings, such as the absence of certain symptoms or conditions.]] Cardiovascular History: [[List each cardiovascular condition separately, including onset, duration, and time.] Example: - Type 1 diabetes - Hypertension] Other Medical History: [[List any other medical history conditions that not on cardiovascular separately, including onset, duration, and time.] Example: - Celiac disease - Hypothyroidism - Parkinson's disease - Detached retina 2007] Cardiovascular Medication: [[List each medication prescribed for cardiovascular health, including the name, dosage, frequency, and timing of administration. Use a bulleted list format to maintain clarity and consistency with the original content.] Example: - Spironolactone 25 mg BID - Irbesartan 75 mg in AM and 150 mg in PM - Tresiba 14 units before breakfast - Fiasp before each meal - ASA 81 mg] Other Medication: [[List each other's medication prescribed that's not for cardiovascular health, including the name, dosage, frequency, and timing of administration. Use a bulleted list format to maintain clarity and consistency with the original content.] Example: - Constella 145 mcg - Amantadine 100 mg TID - Levodopa-carbidopa 100-25 mg TID - Synthroid 137 mcg - Doxycycline 40 mg OD] Allergies: [Present known drug allergies in list form. Use abbreviations and medical shorthand. If none, state "NKDA". Do not use complete sentences.] Family History: [Document family history in list form, using abbreviations and medical shorthand. Include only relevant conditions. Do not use complete sentences. If None, state "Family history is noncontributory."] Social History: [Present social history in extremely concise list form. Do not use complete sentences. Include only essential lifestyle factors.] Physical Examination: [[Provide a detailed narrative of the examination findings. Include the patient's overall condition, specific observations of the lower extremities, noting any edema, its extent, and any asymmetry between sides. Mention any swelling in the feet and toes, and the presence of a positive Stemmer's sign. Note the status of pedal pulses, any signs of infection or wounds, and findings from palpation of the groin, including lymph node status.] Example: On examination, the patient was in no distress. Examination of her lower extremities revealed significant pitting edema bilaterally, worse on the left side. On the right side, it seems to extend up to the level of the knee. On the left side, it does extend all the way up to the hip. Her feet and her toes are swollen and there is a positive Stemmer's sign bilaterally. She does have palpable pedal pulses. There is no evidence of any active infection or wounds. Palpation of her groin revealed possibly enlarged lymph nodes on the right side, and normal lymph nodes on the left side.] Investigations: [[Summarize the findings of diagnostic imaging studies. Include details about the type of imaging, specific findings, any abnormalities noted, and recommendations for follow-up or further testing. Use a narrative paragraph style to maintain consistency with the input content.] Example: X-rays of her knees showed mild osteoarthritis bilaterally. An echocardiogram showed normal LV size and ejection fraction. There is mild aortic, mitral, and tricuspid regurgitation, stable compared to previous. A lower extremity venous duplex showed a right-sided Baker's cyst and a 2.4 cm ovoid structure, possible a complicated cyst, synovial thickening, or an enlarged lymph node. Follow-up with ultrasound in 2-3 months was recommended. There was some venous reflux noted in the right great saphenous vein.] Assessment & Plan: [Summarize the patient's condition and suspected diagnosis in a detail narrative format. Include details about the patient's symptoms, suspected conditions, and any underlying issues.] [Discuss the management plan in a detail narrative format, including conservative management options, exercises, and any recommended devices or therapies. Mention any prescriptions or scripts provided and instructions for their use.] [Address any additional concerns or findings from the examination in a detail narrative format, such as enlarged lymph nodes, and outline any further investigations or tests ordered. Include follow-up plans to review results and adjust treatment as necessary.] Thank you very much for involving me in this [lady's/gentleman's] care.