OPENING SALUTATION
Dear Doctor / Registrar / Dr. Smith / Michael,
Re: Patient … (John Smith) , DOB … (28.6.1985) [DOB – Date of birth]
OPENING CLAUSE [Referral/Admission plus Patient data]
Thank you for (urgently) seeing … (the above patient/ Mrs. Polanski), [Referral letter]
a 38 year-old … (worker, profession) with … (cholelithiasis)
for further … (management) and possible … (operation)
who is currently | in this hospital recovering from … (a stroke)
| suffering from … (severe acute asthma)
| bedridden/immobile with possible … following … on … [combination] (nerve compression) (heavy lifting) (date)
I am writing to refer |my patient aged 45 and married with 3 children of school age.
I am pleased to refer | this 45-years old lady
| Mrs. Smith
| a 45-years-old worker
(This lady of 45years)… was admitted [Admission letter ]
to your facility / this hospital/clinic on … (22.6.21)
for further (neurological) assessment and possible treatment of … (headaches)
operation … (of a hernia)
management of … (her drug substance abuse)
for a fracture of his … (femur)
for post-fracture rehabilitation
I am writing to follow up on our conversation earlier today [Advice letter]
about … (your son’s management plan)
Further to our earlier conversation … (I am reporting you about …)
REASON FOR REFERRAL
(Mr. Dubois) … presented to me (today) with signs of a (possible) … (pulmonary infection)
at my clinic complaining of … (left thorax pain)
to emergency
This 5 yo boy initially presented with … (tonsillitis)
for which he was treated with … (antibiotics)
He is/has been suffering his first episode of … (post-streptococcal nephritis/chest pain)
He was admitted to this hospital on … for a fracture of …
suffering from …
with signs for early renal failure / heart attack
PROVISIONAL DIAGNOSIS (PD) [NYD – not yet diagnosed]
My provisional diagnosis is … (headaches), possibly … (stress-related)
Today, I diagnosed .. / he is diagnosed with …
The complaints may result from … / caused by …
I believe he has / may have … (a urinary tract infection)
I believe that the cause of his complaints is … (an asthma attack)
and is at risk of developing renal failure
Investigation Diagnosis:
The ECG indicated possible … (ischemia)
The liver function tests showed possible … (mild obstruction)
The X-ray detected …
PRESENT ILLNESS
Introduction:
in … (Nov 2003)
on … / today / 6 weeks ago
1) (He)… first attended my clinic for … (a check-up)
complaining of… / suffering from …
with symptoms of … (tonsillitis)
On his first visit to me on …. he was / has been suffering … (a sore throat)
On … Mr Smith presented (at my clinic) complaining of … for the previous 10 days which was not responding to … (simple analgesia)
2) His complaints set in 10 days earlier and were related to … (strong gardening exercise)
SYMPTOMS
The pain occurs … (on exercise)
He was/felt + adjective … (irritable / feverish/ sweaty/ distressed/ nauseated /dehydrated)
suffers from … irritability
complained of …
He presented with … an irritable condition
showed… no guarding or rebound on abdominal examination
found it difficult to …
is unable to … see clearly Apart from this, In addition, noticed
progressively worsening sight Furthermore, he experienced a new episode of pain
Moreover, reported no further … (fever)
Otherwise,
And there is
At times,
Occasionally,
He (initially) had … (headaches), but has had none since that time until … (now / 3 weeks ago)
She reported no history of … (abdominal tenderness)
This causes her stress
He had a decreased range of … (movement on his right hip)
PAST HISTORY (PH) [use simple present tense !]
He has a five year history of … (osteoarthritis)
She has a history of … hypertension (well controlled by medication)
His (medical) history includes (iron deficiency) for which he is given … / treated with …
He also suffers from …
excluding:
She reported no history of dysuria
There has been no history of being overweight/ obesity (98kg at 170cm ht)
He has not suffered from … (epilepsy) or other significant illness/injuries before … (accident)
RISK FACTORS/ALLERGY
His (cardiovascular) risk factors such as … (hypertension)
include … (hypercholesterol, smoking)
being overweight / obesity
lack of regular exercise / having no regular exercise
a strong family history (father died of … aged 48)
Smoking:
She has smoked 15 cig. a day for the past … years
He had cut his smoking to 10 c. a day [past perfect]
Allergy: Please note that she is allergic to … (penicillin)
He has no known allergies
CURRENT MEDICATION
Abbreviations:
stat (latin: statim) – immediately,
BD – twice,
t.d.s./t.i.d. – thrice,
q.d.s./q.i.d. – four times
p.c. – after food, nocte – at night,
s.l. sublingual,
s.c. – subcutaneous
Her current medications include/are…
She also uses … (Mylanta) for … (reflux)
has(not) has not responded to simple analgesia
(No) effect: The pain was (not) relieved by oral medication, Senna, Zantac was persistent
resistant to Coloxyl, Avapro, Panadol
The was pain resisted to … (Aspirin)
His complaint usually settles with NSAID and rest
Side-effect: But the medication caused significant … (dyspepsia)
TREATMENT
Prescription: He was treated here with … (diuretics)
Combination Treatment:
He was given … (oxygen) followed by … (hospital admission)
in addition to … (adrenalin)
combined with … (life support)
and advised on … (losing weight)
I prescribed … (Respeace) combined with … (the Pulmipak)
in addition to
Effect:
Initially, his response to … (fentanyl) was … (good), but unfortunately, his pain flared up.
Therefore, I commenced him on … (morphine)
I changed him on … (frusemide)
After discussion with Dr. X, I started her on …
After persistently elevated BP readings around x mmHg,
Doses: he was commenced/started on …(nifedipin), this has recently been increased to … (20mg)
Operation: An arthroplasty was performed. She underwent/had … (an appendicectomy) and recovered well/ will be discharged today.
Recovery:
She has been able to … (shower) with assistance
Since the operation her wounds have healed and sutures have been removed.
Her post-operative recovery was successful/ uncomplicated /uneventful /normal.
Subsequently,
In the following days, he recovered by taking … (Penicillin) for 7 days.
after 7 days treatment with … (Penicillin)
Complications:
While here, she has (extreme) difficulty using a walking frame/ the crutch
has been able to walk (with extreme difficulty)
to have a shower with assistance
Her short-term memory has worsened while here
Her general condition has deteriorated
EXAMINATION:
neurological he scored … (five) on a short-term memory test
On physical examination this lady showed
cardiovascular I found … no abnormalities
she was overweight with normal vital signs (P80, BP 120/70, T36)
The examination was unremarkable / normal
revealed … (elevated liver enzymes, no abnormalities)
(Bilateral fine crepitations) … were noted on chest auscultation / examination
Otherwise, examination was normal.
Readings:
The (liver function tests) … showed (no) pathological findings
(FBC, MSU, ASOT) significant abnormalities
were consistent with … (hepatic failure)
He had elevated BP readings around 150/1000
The blood test was normal and Urea, Creatinine was slightly elevated
Technical Investigations:
Tests including … An Xray/ECG/radiograph taken here on … revealed … NSA (no signifcant abnormalities)
indicated … Test for/on … (Mr. Smith) were done and showed …
I had test for … (Mrs. Jones) done which showed …
I ordered the following test for … (Michael):
Results:
All tests, in summary, indicate pathological findings consistent with … (hepatitis)
confirm my provisional diagnosis of … (post-streptococcal nephritis)
(The urine analysis) … showed / confirmed significant … (haematuria)
(Her liver function tests) … showed possible … (mild obstruction)
The … (CT scan) at that time appeared … (unremarkable/ normal)
ACTUAL CONSULTATION [Review, follow-up visit]
On review (Today), … (Mr. Romano) reports no further episodes of … (headaches)
presented persisting complaints
reviewed me due to … (brown urine) for 4 days.
On review, investigations showed … and haematuria of renal origin.
One month later, he returned today with the symptoms above.
PSYCHOLOGICAL ISSUES /CONCERNS
was anxious
She showed concerns that she may have … (cancer), about which I have reassured her.
worried
She is most concerned of …
She is a widow and has managed alone until now.
He receives support from … to manage
He needs assistance requires
ADVICE
He was advised to …(take antibitotics) and return in … (2 days)
on … (losing weight)
Mrs. Smith was given advice on … (quitting smoking)
I advised her (that she may need) to represent to hospital for admission …
if she gets any worse or if she isn’t getting better in 2 days.
To avoid future episodes, he needs … (to carry medical ID at all times stating he is diabetic)
REQUEST/FUTURE MANAGEMENT
Thank you for continuing the care of … (this lady) [discharge letter]
I would appreciate your further assessment and management/treatment
regarding … (his acute worsening condition).
of the possibility of … (cancer)
of the suspected/potential cancer
I would appreciate
I would be grateful
(for) your opinion regarding … (his future management)
if you could please assess this patient
if you could see … (this lady) fairly soon for further management.
if you could arrange an appointment with a physiotherapist/ an occupational therapist /a social worker
I would be interested if he would be a suitable candidate for … (a hip replacement)
I would appreciate if you could keep me informed about his further management.
