Dr. Eleanor Vance
Thank you for considering this referral of Sarah, whom I reviewed for persistent fatigue, recurrent infections, and abnormal blood counts requiring further investigation. Sarah has been experiencing increasing fatigue over the past six months, accompanied by frequent upper respiratory tract infections and bruising. Her recent blood tests have revealed a low white blood cell count and thrombocytopenia. She is currently stable but requires further assessment to determine the underlying cause of her symptoms.
Medical History:
- Appendectomy at age 10
- No known allergies
Medication Listing:
- Paracetamol 500mg as needed for headaches
Investigations:
- 15 October 2024: Full Blood Count - White blood cell count 2.8 x10^9/L (low), Platelets 80 x10^9/L (low)
- 20 October 2024: Peripheral Blood Smear - Shows atypical lymphocytes and reduced platelets.
- 25 October 2024: Bone Marrow Biopsy - Pending
Thank you for your assistance with this referral and the ongoing care of the patient. I would appreciate receiving a copy of your correspondence. Please notify my rooms if the patient fails to attend your consultation and/or is unable to be contacted.
Patient can be contacted via email at sarah.jones@email.com or by phone at 07700 900000.
Sarah requires wheelchair access.
I will review Sarah again on 1 December 2024.
[Full name of doctor who has been referred]
Thank you for considering this referral of [patient's first name], whom I reviewed for [their condition, symptoms or results requiring further investigation]. [Summarise the patient's current status, including reasons for referral, any new medical illnesses, changes in medication, or resolution of previous conditions, and overall well-being.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single paragraph of full sentences.)
Medical History:
[document patient's medical history, including significant past illnesses, surgeries, and relevant diagnostic results] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as bullet points with "-".)
[document relevant family medical history] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as bullet points with "-".)
Medication Listing:
[list current and relevant past medications, including dosage and frequency if provided] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as bullet points with "-".)
Investigations:
[list relevant investigation results with corresponding dates and specific findings, including laboratory tests and imaging results] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list. Order chronologically from oldest to most recent. Each entry should begin with the date, followed by test name and findings on subsequent lines.)
Thank you for your assistance with this referral and the ongoing care of the patient. I would appreciate receiving a copy of your correspondence. Please notify my rooms if the patient fails to attend your consultation and/or is unable to be contacted.
[document how the patient is best contacted] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[note any accessibility requirements the patient may have] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[explain when the patient will be seen next by practicing doctor] (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.)