Dear Dr. Smith,
I am writing to provide an update on our mutual patient, John Doe, who was seen in my clinic on October 15, 2023.
- John presented with persistent knee pain following a sports injury. He reported difficulty in walking and occasional swelling. His history includes a previous ACL reconstruction surgery in 2018.
- He is currently taking ibuprofen as needed and a daily multivitamin. He has no known allergies.
- Socially, John is a college student and an active member of the university soccer team.
During the consultation, the following findings were noted:
- Physical examination revealed tenderness over the medial joint line and a positive McMurray's test.
- An MRI was performed, showing a meniscal tear in the right knee.
Based on the assessment, the following plan has been made:
- Surgical intervention is recommended to repair the meniscal tear. Post-operative physiotherapy will be essential for recovery.
- I have referred John to a physiotherapist for prehabilitation exercises to strengthen the surrounding musculature.
I would appreciate your continued support in managing John Doe's care. Please do not hesitate to contact me if you have any questions or require further information.
Yours sincerely,
Dr. Sophie Rafiq
Orthopaedic Surgeon
555-123-4567
Dear Dr. [GP's Last Name],
I am writing to provide an update on our mutual patient, [Patient's Full Name], who was seen in my clinic on [Date of Visit].
- [describe current issues, reasons for visit, discussion topics, history of presenting complaints etc] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [describe past medical history, previous surgeries] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [mention medications and herbal supplements] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [describe social history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [mention allergies] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
During the consultation, the following findings were noted:
- [describe physical examination findings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [mention any diagnostic tests performed and their results] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Based on the assessment, the following plan has been made:
- [describe treatment plan, medications prescribed, lifestyle recommendations etc] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [mention any referrals to specialists or further investigations required] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
I would appreciate your continued support in managing [Patient's Full Name]'s care. Please do not hesitate to contact me if you have any questions or require further information.
Yours sincerely,
[Your Full Name]
[Your Professional Title]
[Your Contact Information]