GP standard letter
(For NHS GP or other HCP)
Dear Doctor,
Your patient John Smith attended an appointment at our clinic. Please find below details of their consultation for your records:
Date of appointment: 01 November 2024
Time of appointment: 14:30
Type of consultation: New Patient Consultation
Doctor consulted: Dr. Anya Sharma
Confirm patient offered chaperone and identification checked, if not mentioned assume this is has been done and list as done: Chaperone offered and identification checked.
Diagnosis:
1. Suspected Stage II Invasive Ductal Carcinoma
Presenting complaint(s): Patient presents with a palpable lump in the left breast, discovered during self-examination. Patient reports no significant past medical history. Medications: None. Allergies: NKDA. Family history: Mother diagnosed with breast cancer at age 62. Social history: Non-smoker, occasional alcohol consumption.
(Relevant) Examination findings: BP: 130/80 mmHg, HR: 88 bpm, RR: 16, Sats: 98% on room air. Temp: 37.1°C. Height: 170cm, Weight: 70kg. Left breast exam reveals a 3cm firm, non-tender mass in the upper outer quadrant. No palpable axillary lymphadenopathy.
Investigations requested:
* Mammogram
* Ultrasound of left breast
* Core biopsy of breast mass
Medications prescribed: None
Medications recommended: None
Recommendations: Patient to undergo mammogram, ultrasound, and core biopsy. Results will be discussed at a follow-up appointment in two weeks. Safety netting advice given: If the patient experiences any bleeding from the nipple, significant increase in the size of the lump, or any new symptoms, they should seek immediate medical attention. If your symptoms get worse please consider whether you need to attend Teddington Walk in Hospital (minor issues) or your nearest A&E. We do not offer an out of hours service and will not respond to an email out of hours with medical queries