EPC Letter Template

Dr. Emily Johnson Healthy Moves Physiotherapy 123 Wellness Street Springfield, IL, 62701 (555) 123-4567 emily.johnson@healthymoves.com November 15, 2023 Dear Dr. Sarah Thompson, Re: Enhanced Primary Care (EPC) Plan for John Doe, 01/15/1980, (555) 987-6543 I am writing in regard to John Doe, 01/15/1980, who has had an initial consult as part of their Enhanced Primary Care (EPC) plan. The details of the patient's current health status and the proposed management plan are outlined below. Presenting condition: John presented with chronic lower back pain, which began six months ago. The pain is aggravated by prolonged sitting and has been partially managed with physical therapy and pain medication. The condition significantly impacts his ability to perform daily activities, including work-related tasks. Medical History: John has a history of hypertension and underwent knee surgery in 2015. Current Medications: John is currently taking Lisinopril 10mg daily for hypertension and Ibuprofen 400mg as needed for pain. Allergies: John has no known allergies. Social History: John is a non-smoker and consumes alcohol occasionally. He lives with his spouse and two children and has a supportive family network. Proposed Management Plan: The proposed management plan includes a tailored exercise program focusing on core strengthening and flexibility, bi-weekly physiotherapy sessions, and a referral to a dietitian to support weight management. Progress will be monitored through regular assessments and patient-reported outcomes. Thank you for your coordination of their care. Yours sincerely, Dr. Emily Johnson BSc (Physiotherapy), MPT Healthy Moves Physiotherapy Thank you for referring John. I saw John, aged 43 years, for review of their progress post sleeve gastrectomy on 08/01/2023, at 12 weeks post-surgery. Related issues: John has experienced mild nausea and occasional dizziness post-surgery. Background to condition: John gained weight due to a sedentary lifestyle and poor dietary habits. Anthropometry: Current weight: 85 kg, Height: 180 cm, BMI: 26.2 kg/m². 15% weight loss from baseline steady weight: 100 kg on 01/01/2023. Down by 15 kg over 10 months. 10% weight loss from weight at the time of surgery: 95 kg on 08/01/2023. Down by 10 kg over 3 months. Expected total weight loss at 12-18 months: 25 kg or 25%. Current average weekly rate of weight loss: 0.8 kg/week. Previous weight loss attempts: John has tried various diets and exercise programs with limited success. Weight history: Weight history over lifespan: Heaviest adult weight: 110 kg. How the patient feels about current body image and weight: John feels more confident and motivated to maintain a healthy lifestyle. Dietary assessment: Regularity of eating pattern: Consistent with three meals a day. Portion sizes: Appropriate and controlled. Comparison of diet against Australian dietary guidelines: Generally adheres to guidelines with occasional indulgences. Eating behaviours: Mindful eating practices have improved. Social: John drinks socially and does not smoke. Living arrangements: Lives with family. Employment/study and hours of work: Works full-time as an accountant. Physical activity: Current activity level: Engages in moderate exercise 4 times a week. Past activity level: Previously sedentary. How the patient feels about physical activity: John enjoys physical activity and finds it beneficial for stress relief. Bowels: Current bowel habits: Regular with no issues. Bowel history: No significant history. Client perspective: Why the patient wanted to have the surgery: To improve health and quality of life. Current feelings about the surgery and progress: John is pleased with the results and committed to ongoing lifestyle changes. Multivitamins: John is compliant with the multivitamin regimen. Medications: Lisinopril 10mg daily, Ibuprofen 400mg as needed. Education: Provided education on maintaining a balanced diet and the importance of regular physical activity. Written materials provided: Handouts on post-surgery care and exercise routines. Plan: Continue with the current exercise program, monitor progress, and follow up with the dietitian. Thank you for your referral. The next review appointment is on December 15, 2023. Feel free to contact me with any questions. I look forward to following up. Kind regards, Dr. Emily Johnson