General Surgery Consult Letter Template

Dear 

Thank you for referring Ms. Emily Carter for evaluation of autoimmune thyroiditis and associated symptoms.

History:
Ms. Emily Carter is a female lady referred for autoimmune thyroiditis and associated symptoms. She reports persistent fatigue for the past three months. She also notes weight gain, irregular menstrual cycles, morning joint stiffness, hair thinning, constipation, and increased sensitivity to cold temperatures. 

Past Medical History:
- Autoimmune thyroiditis (E06.3)
- Vitamin D deficiency, unspecified (E55.9)

Past Surgical History:
There is no past surgical history.

Medications:
- Levothyroxine 50 mcg daily
- Vitamin D 2000 IU daily

Allergies:
No known medication allergies

Family History:
Ms. Emily Carter's mother has a history of Hashimoto’s thyroiditis.

Social History:

Physical Exam:

Investigations:
Laboratory, 2026-01-24: Elevated TSH (7.8), low-normal free T4, positive anti-TPO antibodies, mild Vitamin D deficiency.

Impression & Recommendations:
In summary, Ms. Emily Carter was seen for autoimmune thyroiditis and associated symptoms.

I discussed with the patient the natural history of autoimmune thyroiditis progression and reviewed both non-operative and surgical management options. For non-operative management, this includes thyroid hormone replacement and vitamin D supplementation. 

Thank you again for allowing me to participate in the care of Ms. Emily Carter. If you have any questions or concerns, please do not hesitate to contact me.

Sincerely,
Dr. Alex Lin