Dear Dr. Emily Carter,
Thank you for referring John Smith, whom I reviewed in the high-risk anaesthetic clinic along with his wife, Sarah. He is being considered for a hip replacement.
Mr. Smith has:
- Hypertension, Type 2 Diabetes, and a history of a previous myocardial infarction. Previous surgeries include a coronary artery bypass graft (CABG) 5 years ago.
Current medications and supplements:
- Aspirin 75mg daily, Metoprolol 50mg twice daily, Lisinopril 10mg daily, and Insulin. No known allergies.
They live with his wife in a bungalow. He is fully independent, can climb stairs with some difficulty, and leaves the house daily for short walks. He can walk for about 10 minutes before experiencing mild chest pain.
Upon evaluation, the following findings were noted:
- Blood pressure 140/85 mmHg, ECG shows sinus rhythm with old inferior infarct changes. ECHO shows mild left ventricular hypertrophy.
Their airway assessment showed:
Mallampati: Class II
Mouth opening: Adequate
Neck movement: Full
Dentition: Good
We had a thorough discussion about the intended benefits of surgery, the risks, and the potential implications balanced against the option of doing nothing and continuing as they are. In particular, we discussed the risks of general anaesthesia, including the risk of aspiration, cardiac arrest, and stroke.
We also discussed the general risks associated with any operation, including complications such as a heart attack, stroke, chest or kidney infection, and ultimately death. We talked about how a perioperative complication may delay recovery and reduce the chances of returning to an independent existence. We noted that the only way to entirely avoid these risks is to forgo the surgery, but this would, of course, mean they would not benefit at all.
Should you wish to proceed, please ensure that they have the standard pre-operative assessment. They will need to withhold Insulin prior to surgery.
Yours sincerely,
Dr. Irfan Raza
Consultant Anaesthetist
Dear [Referring Clinician's Name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.),
Thank you for referring [Patient's Name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.), whom I reviewed in the high-risk anaesthetic clinic along with [relative] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.). He/She is being considered for [reason for referral] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.).
Mr/Mrs has:
- [list past medical history, previous surgeries] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Current medications and supplements:
- [mention medications and herbal supplements and allergies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
They live with [describe home environment, level of independence, whether they can climb stairs, whether they leave the house, if they do how far they can walk, how long it takes them and whether they get any chest pain or breathlessness] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Upon evaluation, the following findings were noted:
- [describe blood test, ECG result, ECHO result or lung function tests, or imaging etc] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Their airway assessment showed:
Mallampati:
Mouth opening:
Neck movement:
Dentition:
We had a thorough discussion about the intended benefits of surgery, the risks, and the potential implications balanced against the option of doing nothing and continuing as they are. In particular, we discussed the risks of [describe the type anaesthetic and the risks associated with it] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
We also discussed the general risks associated with any operation, including complications such as a heart attack, stroke, chest or kidney infection, and ultimately death. We talked about how a perioperative complication may delay recovery and reduce the chances of returning to an independent existence. We noted that the only way to entirely avoid these risks is to forgo the surgery, but this would, of course, mean they would not benefit at all.
Should you wish to proceed, please ensure that they have the standard pre-operative assessment. They will need to withhold [medicine name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) prior to surgery.
Yours sincerely,
Dr Irfan Raza
Consultant Anaesthetist
(For each section, only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps — use only the transcript, contextual notes or clinical note as a reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines or paragraphs as needed to capture relevant information.)