Sports Medicine - Specialist Letter to Referrers and interested parties

[insert today's date] Thank you for referring [insert patient's title (Mr or Ms followed by patient's surname)], a [insert age (round down to nearest whole number)]-year-old [insert sex (male or female)] who works as a [insert occupation], for assessment and management of [insert presenting complaint]. This review was performed in co-consultation with Specialist Sport and Exercise Physician Dr George Pitsis. History of Presenting Complaint: [detail the chronology of the patient's presenting complaint, including symptoms prior to and including today's presentation. Include symptom severity, functional impact (occupation, mobility, ADLs, sport), and timeline of progression] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.) Investigations: [list all imaging investigations prior to today's review in chronological order starting from most recent. For each, include: Imaging Modality, Date of Investigation, Imaging Centre, and radiologist's summary findings] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as numbered list.) Current Therapies/Treatments: [document all treatment modalities received so far, in chronological order. Include non-pharmacological (e.g. physiotherapy, massage, bracing), pharmacological (e.g. NSAIDs, opioids), and procedural (e.g. PRP, corticosteroid injections, radioablation) interventions] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in bullet points.) Background Medical History: [list all active medical problems, current medications (with dose/frequency), allergies, alcohol and smoking history, and relevant family history] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as short bullet point list or brief paragraphs.) Examination: [detail all positive and negative findings from physical examination, including any objective clinical measurements e.g. vitals, range of motion, functional tests] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.) Diagnosis: [insert patient's name (use Mr or Ms followed by patient's surname)] presents with clinical and radiological features consistent with [insert provisional diagnosis]. Differential Diagnoses: [insert list of differential diagnoses, each with brief justification] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet point list.) Management: I have discussed [insert patient's title (Mr or Ms followed by patient's surname)]'s problems with them today, and recommended the following management of their condition: - [insert first management plan item] - [insert second management plan item] - [insert third management plan item] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write each item as one full sentence per bullet point.) Further treatment options were discussed including optimisation of non-operative management with ultrasound-guided injections, and referral to an Orthopaedic Specialist for consideration of operative management of this injury. Follow-Up Plan: I would appreciate the opportunity to review [insert patient's title (Mr or Ms followed by patient's surname)] in [insert review interval] to assess their response to the recommended treatment plan and to assess their progress with the [insert type of rehabilitation plan (physiotherapy-based or gym-based)] rehabilitation program. (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentences.) Once again, many thanks for giving me the opportunity to assist with management of your patient. If you have any further questions, please do not hesitate to reach out to me. Warm regards, Dr Jonathan Attia MBBS; MSpMed Co-Consulted with Specialist Sport and Exercise Physician Dr George Pitsis Provider No. [Insert provider number] [Clinic contact details] cc: [insert name and clinic of Orthopaedic Surgeon, if applicable] cc: [insert name and clinic of Physiotherapist, if applicable] cc: [insert name and clinic of Exercise Physiologist, if applicable] cc: [insert name and clinic of any other health professional involved, if applicable] (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.)