WOPC Consult Letter

Chief Complaint

RE: Referral

Template

Consultation visit [today's date] Thank you for referring this [age] year-old [gender] for assessment and treatment of [side] [body part] pain. ASSESSMENT: [Summary of assessment including the structures that are causing the patient's pain and my clinical reasoning for the assessment. For example: "Joel's chronic neck pain and headaches are caused by laxity of the semispinalis capitis muscle as it anchors to the midline. His examination today showed that his shoulder abduction was weak on the right side and improved immediately when it provided anchoring pressure over this area of fascia injury at the posterior neck. His recent low back pain may be its own individual problem or it may be linked to the chronic neck injury. I expect his neck and headache symptoms will respond quite well to platelet-rich plasma injections. He may need 3-4 sessions total for 80-90% symptom reduction."] PLAN: [Summary of my recommendations including the type of injections that I recommended, how many sessions I think the patient needs. Document my discussions of potential risks, and red flag symptoms to watch out for after injection. Use the full sentences and the active voice in this section. Do not use the passive voice. For example, "I discussed with him the risks of soft-tissue infection (1:30,000), joint infection (1:30,000) bruising, and post-treatment pain. He understands to monitor for redness, swelling, and fever after injections. If he develops any of these symptoms, he should call my clinic or go to the emergency department. I will see him at a separate appointment for assessment of his low back. He will likely need platelet-rich plasma injections targeting the right SI joints and ligaments supporting the innominate bone based on his previous history of severe trauma in that area. Other than injections, he could also be optimized from a muscle balance point of view. He stands with his wrists in full pronation, which means he needs to build strength in the muscles that supinate his wrists and in the muscles that externally rotate his shoulders. This would be treated with exercise-based rehabilitation. He would likely benefit from kinesiology services at Telus Health. He has an upcoming blood test scheduled with Telus Health next week, and will make sure that a CBC is included on the order. He will have a copy of the blood test sent to me, and once I have reviewed it and deemed it safe to proceed with PRP and that he has enough platelets for it to be effective, I will have my office contact him to book the PRP treatment." ] PROCEDURE: Consent was obtained. Sterile technique was used with injections. Aspiration was negative for air and blood prior to all injections detailed below. Chaperone: None. Treatment was tolerated well without complications. ------------------------------------------------------------------------------------ HISTORY OF PRESENTING ILLNESS: Occupation: [patient's occupation] Location of pain: [location of pain. Where applicable, include whether the pain is felt as deep. Include characteristics of the pain such as ache, sharp, burning, etc.] Duration of pain: [duration of pain] Mechanism of injury: [mechanism of injury. Include information about past major traumas such as history of concussions, falls, accidents, fractures, major sprains and injuries.] Aggravating factors: [Aggravating factors. Include information on patient's tolerance for aggravating activities, such as how long they can walk, sit, or stand, and whether the patient has had to discontinue certain activities.] Alleviating factors: [alleviating factors] Denies the following: [symptoms. Specifically include "saddle anesthesia" (or lack thereof) if I ask the patient about "numbness around the genitals or butt crack". Specifically include whether there is bowel incontinence or difficulty passing urine.] [HPI information. Do not include past medical history, surgical history, medications, or allergies here. Do not include patient's age here. Do not include location of pain, duration of pain, mechanism of injury, aggravating factors, alleviating factors here. Include information on how the pain affects the patient's function. When it is in the transcript, include details about if there is clicking, popping, sensation of fine crepitus (i.e. when I ask whether the patient experiences the sound of crinkling plastic or rice crispies), or sensation of instability. If there is mention of a motor vehicle accident, include information such as the mechanism of the crash, where the patient was sitting in the vehicle, what kind of vehicle they were driving, what other kinds of vehicles were involved in the crash, whether patient was wearing a seat belt, whether air bags were deployed, whether the patient lost consciousness, and other relevant information regarding the accident.] [PAIN LEVELS: do not fill in below if pain levels were not reported in the transcript] [Worst pain over past 24 hours: e.g. 7/10] [Least pain over past 24 hours: e.g. 3/10] [Average pain: e.g. 6-8/10] INVESTIGATIONS: [Past Imaging study impressions, listed in point-form. A new bullet point should be used for each different investigation.] CURRENT TREATMENTS: [list of current treatments such as physiotherapy, IMS, acupuncture, massage therapy, kinesiology. Do not include medications that are not used in pain management. Each item in the list must be preceded by a bullet point.] PAST MEDICAL HISTORY: [list of past medical history. Each item in the list must be preceded by a bullet point] SURGICAL HISTORY: [list of past surgeries. Each item in the list must be preceded by a bullet point.] MEDICATIONS: [list of current medications. Each item in the list must be preceded by a bullet point.] ALLERGIES: [Allergens, and their corresponding allergic reactions. Each item in the list must be preceded by a bullet point.] SOCIAL HISTORY: [In sentence form, include information about whether the patient has extended health benefits, who they live with, whether they are married, whether they have children, and other relevant social information.] EXAMINATION: [list of exam findings as in the following example format: Appearance: Comfortable at rest Right scapula depressed and downward rotated Muscle atrophy of the right infraspinatus Active range of motion: -Flexion: Left - 170, Right - 160, moderate winging on the right on return from flexion -Abduction: Bilateral - 170, no winging on return from abduction -Internal rotation: Left - hand to gluteal area Impingement tests: -Hawkin: positive -Neer: positive Rotator cuff tests: -Empty can: Left - painful but not weak -Resisted ER: Left - negative -Subscapularis lift off: Left - negative Other special tests: -Speed: Left - negative -O'brien: Left - negative -Scarf: Left - negative -Scapular winging: on descent from abduction SI joint tests: -One finger test: negative -Tenderness over the PSIS: negative -Distraction: negative -Compression: negative -Thigh thrust: negative -FABER: negative -Gaenslen: negative -Manual gaping of the SI joint: negative -SI joint unlocks with movement to sit on the left -Innominate rotation: left anterior Neurologic examination: -Sensation: normal in all dermatomes of the upper limbs -Motor: normal in all myotomes of the upper limbs -Tone: normal, no clonus -Deep tendon reflexes: normal in both biceps, triceps, and brachioradialis tendons ] [Point of care ultrasound examination: list of findings in point form] Thank you for involving in the care of this patient, Dr. Xiao Yuan MD CCFP D-CAPM Medical Director, White Oak Pain Clinic