General Surgeon Template

Post Surgical Follow-up Letter

A professional General Surgeon template for healthcare professionals.

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Specialty

General Surgeon

Used

78 times

Type

Note

Last edited

9/10/2024

Created by

Alun Jones

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About this template

The Post Surgical Follow-up Letter template is designed for general surgeons to document patient encounters in the Emergency Surgery Ambulatory Care setting. This template facilitates the recording of diagnoses, investigations, and treatment plans, ensuring comprehensive documentation of patient history, examination findings, and follow-up plans. It is particularly useful for conditions requiring surgical intervention, such as appendicitis. The template's structured format aids in efficient and accurate note-taking, which can be seamlessly integrated into Heidi, the AI medical scribe, enhancing workflow and patient care.

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Diagnosis: Acute Appendicitis CT Scan: Confirmed inflamed appendix Blood Tests: Elevated white blood cell count, C-reactive protein elevated, normal liver function tests. Plan: Laparoscopic appendectomy. Post-operative antibiotics. It was a pleasure to meet you this morning in the Emergency Surgery Ambulatory Care (ESAC) clinic. You were accompanied by your spouse. You present with a 2-day history of severe abdominal pain. You tell me the pain started around your navel and then moved to the lower right side of your abdomen. It was associated with nausea but has not affected your appetite. You are also telling me that you've had a mild fever. Your past medical history comprises hypertension, and you currently take Lisinopril for this. You're also taking Metformin for type 2 diabetes. On examination today, you appeared in moderate distress and were ambulatory with difficulty. Your BMI was approximately 28 (85 kg). The abdominal examination disclosed tenderness in the right lower quadrant with rebound tenderness. I see that recent blood tests have shown leukocytosis. It also showed elevated C-reactive protein. An abdominal ultrasound scan today was inconclusive and in particular showed no gallstones. We are awaiting surgical clearance. In the meantime, I have reassured you that the surgery is routine and typically has a quick recovery. You may benefit from a follow-up ultrasound to ensure no complications post-surgery. We'll keep you updated with regards to your surgery schedule.