Dear Dr. Smith,
I am writing to provide an update on our mutual patient, Jane Doe, who was seen in my clinic on 1 November 2024.
Jane Doe presented with concerns regarding a previous breast augmentation. She reported dissatisfaction with the aesthetic outcome and asymmetry. The patient also reported a history of capsular contracture in the left breast. Discussion topics included revision options, risks, and benefits of further surgery, and expectations.
During the consultation, we discussed her past medical history, including the previous breast augmentation and subsequent revision. She has had no previous surgeries other than the breast augmentation and revision.
Jane Doe is currently taking no medications or herbal supplements.
Jane Doe has reported no known allergies.
The physical examination revealed asymmetry of the breasts, with the left breast appearing firmer and more contracted than the right. There was also some malposition of the implants.
My assessment is that Jane Doe is experiencing capsular contracture in the left breast and asymmetry requiring revision.
The plan moving forward includes a revision breast augmentation with capsulectomy and implant exchange on the left side. I have advised Jane Doe to avoid smoking and to follow post-operative instructions carefully. Follow-up appointments will be scheduled to monitor healing and aesthetic outcome.
Please do not hesitate to contact me if you require any further information or if you have any questions regarding Jane Doe's care.
Sincerely,
Dr. Thomas Kelly
Plastic & Reconstructive Surgeon
123 Harley Street, London, UK, 020 7123 4567
Dear Dr. [GP's Last Name] (only include GP's Last Name if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.),
I am writing to provide an update on our mutual patient, [Patient's Full Name] (only include Patient's Full Name if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.), who was seen in my clinic on [Date of Visit] (only include Date of Visit if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.).
[Patient's Full Name] presented with [list current issues, then describe reasons for visit, discussion topics, history of presenting complaints etc] (only include describe current issues, reasons for visit, discussion topics, history of presenting complaints etc if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.).
During the consultation, we discussed [describe past medical history, previous surgeries] (only include describe past medical history, previous surgeries if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.), and [mention medications and herbal supplements] (only include mention medications and herbal supplements if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.). Additionally, [describe social history] (only include describe social history if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) was reviewed.
[Patient's Full Name] has reported [mention allergies] (only include mention allergies if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.).
The physical examination revealed [describe physical examination findings] (only include describe physical examination findings if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.).
My assessment is that [Patient's Full Name] is experiencing [describe assessment, diagnosis] (only include describe assessment, diagnosis if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.).
The plan moving forward includes [describe plan, interventions, treatment recommendations] (only include describe plan, interventions, treatment recommendations if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.). I have advised [Patient's Full Name] to [describe patient advice, follow-up instructions] (only include describe patient advice, follow-up instructions if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.).
Please do not hesitate to contact me if you require any further information or if you have any questions regarding [Patient's Full Name]'s care.
Sincerely,
[Your Full Name] (only include Your Full Name if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
[Your Title] (only include Your Title if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
[Your Contact Information] (only include Your Contact Information if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
(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 include 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.)
