Dr. Eleanor Vance
123 Fertility Clinic Lane
London, UK
Date: 1 November 2024
Dear Dr. Vance,
Re: Emily Carter, DOB: 12/03/1988
Thank you for referring Emily Carter to my care for investigation of primary infertility.
Clinical Summary:
Emily, a 36-year-old female, presents with a 2-year history of trying to conceive without success. She has regular menstrual cycles. Her partner, John, has had a semen analysis which was normal.
Current Presentation:
Emily reports no significant symptoms. She is concerned about her age and the time it is taking to conceive. Her functional status is good; she is working full-time and maintaining an active social life.
Past Medical History:
- No significant past medical history.
- Family history of early menopause in her mother.
Medications:
- Folic acid 400mcg daily.
- No known drug allergies.
Examination Findings:
Physical examination was unremarkable. BMI 24. Pelvic exam normal.
Investigations:
- Day 3 FSH: 8.2 IU/L
- AMH: 1.8 ng/mL
- Pelvic ultrasound: Normal uterus and ovaries. No evidence of fibroids or cysts. Antral follicle count: 8.
Impression/Diagnosis:
Primary infertility, likely related to diminished ovarian reserve.
Management Plan:
- Discussed options for fertility treatment, including ovulation induction with timed intercourse, intrauterine insemination (IUI), and in vitro fertilisation (IVF).
- Recommended further investigations, including a hysteroscopy to assess the uterine cavity.
- Offered counselling regarding the emotional aspects of infertility.
- Scheduled follow-up appointment in 4 weeks to review hysteroscopy results and discuss treatment options in more detail.
Thank you again for your referral. I will keep you updated on Emily Carter's progress.
Yours sincerely,
Dr. Thomas Kelly
Consultant Reproductive Endocrinologist
The Fertility Clinic
020 7123 4567
Dr. [Referring Doctor's Full Name]
[Referring Doctor's Address]
Date: [Current Date]
Dear Dr. [Referring Doctor's Last Name],
Re: [Patient's Full Name], DOB: [Patient's Date of Birth]
Thank you for referring [Patient's Full Name] to my care for [reason for referral].
Clinical Summary:
[Provide a concise summary of the patient's relevant medical history, presenting complaint, key findings from examination, and any significant investigations completed to date.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Current Presentation:
[Describe the patient's current symptoms, their duration, severity, and any aggravating or relieving factors. Include details of the patient's functional status and impact of their condition on daily life.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Past Medical History:
- [List relevant past medical conditions, significant illnesses, previous surgeries, and hospitalizations.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
- [Detail any relevant family medical history.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Medications:
- [List current medications, including dosage, frequency, and route. Note any allergies or adverse drug reactions.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Examination Findings:
[Document relevant findings from the physical examination, including vital signs, system-specific examinations, and any notable observations.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Investigations:
- [Summarize results of any relevant investigations performed, such as laboratory tests, imaging studies, or other diagnostic procedures.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Impression/Diagnosis:
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Management Plan:
- [Outline the proposed management plan, including further investigations, treatments, referrals to other specialists, and follow-up arrangements.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
- [Detail any patient education or counselling provided.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Thank you again for your referral. I will keep you updated on [Patient's Full Name]'s progress.
Yours sincerely,
[Clinician Full Name]"
[Clinician Professional Title]
[Clinic/Practice Name]
[Contact Information]
(Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)