Premenstrual Mood Disorder

Chief Complaint

Consult Letter Template

Template

Dear [referring_physician_name], Thank you for referring [patient_name], a [age]-year-old [sex], who was seen on [date] for assessment of [reason_for_consult]. Consent: Consent was obtained from the patient for the use of AI-assisted documentation tools. History of Presenting Illness: Patient presents with [symptom] for [duration]. Symptoms include: - Vasomotor symptoms: [present/absent] - Sexual dysfunction: [present/absent] - Urinary symptoms: [present/absent] - Irritability: [present/absent] - Anger: [present/absent] - Depression/anhedonia: [present/absent] - Musculoskeletal symptoms: [present/absent] - Gastrointestinal symptoms: [present/absent] - Weight changes: [description] - Severity of symptoms: [description] - Timing of symptoms in relation to menses: [description] Relevant history includes: - Coronary artery disease: [present/absent] - Bone fractures: [present/absent] - Migraines: [present/absent] - Breast cancer: [present/absent/prior] - Venous thromboembolism: [present/absent/prior] Past Medical History: [medical_history] Medications: [medication_name], [dose], [frequency], [route], [duration] Allergies: [allergies] Social History: - Exercise: [exercise] - Meals: [meals] - Work: [work] - Extended coverage: [coverage] - Alcohol use: [alcohol] - Cigarette use: [cigarettes] - Drug use: [drugs] Family History: [family_history] - Family history of breast cancer: [present/absent] Physical Examination: - General exam: [exam_finding] - Weight: [weight] - Height: [height] - Blood pressure: [value] - Heart rate: [value] - Cardiac exam: [exam_finding] - Pulmonary exam: [exam_finding] Investigations: [investigations] Impression and Plan: [patient_name] is a [age]-year-old [sex] with [symptoms]. Based on the history and findings, the likely diagnosis is [diagnosis]. 1. [Diagnosis/Condition]: - [Action plan, e.g., "I have initiated..."] - [Additional management steps] 2. Non-pharmacologic management: - Recommend [specific lifestyle modifications, e.g., "150 minutes of moderate to intense exercise per week"] - Advise monitoring for [specific triggers or symptoms] 3. Follow-up: - Arrange follow-up in [timeframe, e.g., "1 month/3 months/6 months"]. **Patient Counseling:** The patient was counseled on [specific risks, benefits, and side effects of treatment]. Thank you for involving me in the care of this patient. Please do not hesitate to contact me with any questions or concerns. Sincerely, [Your Name], MD, [Your Credentials]