Dear Doctor,
Thanks for your referral. I had the pleasure of seeing John Smith today in my rooms.
Background:
* Gastro-oesophageal reflux disease (GORD)
* Irritable bowel syndrome (IBS)
Past Surgical History:
* Appendectomy at age 10
Past Gastroscopy/Colonoscopy:
* Colonoscopy performed 2 years ago, showing mild diverticulosis.
Family History:
* Mother with history of coeliac disease.
Medications:
* Omeprazole 20mg daily, Buscopan as required.
Allergies:
* Penicillin
Social history:
* Lives with wife, works as a teacher, independent with mobility, enjoys gardening, socialises with friends regularly, non-smoker, drinks alcohol occasionally.
Progress:
* The patient presents with a 6-month history of intermittent heartburn and regurgitation, worse after meals and when lying down. He reports that antacids provide some relief. He denies any dysphagia or odynophagia. He has no vomiting, melaena, or PR bleeding. Bowel habits are unchanged. There has been no unintentional weight loss. He denies fevers or rigors. Appetite is good. No history of iron deficiency.
Examination:
* BMI 28. Abdomen soft, non-tender. No palpable masses or organomegaly.
Investigations:
* Blood tests: Normal full blood count, liver function tests, and coeliac serology.
Active GI issues:
1. Gastro-oesophageal reflux disease (GORD):
* Assessment: Typical symptoms of heartburn and regurgitation, responsive to antacids. No alarm symptoms.
* Likely Diagnosis: GORD.
* Rationale: Symptom history and response to medication.
2. Irritable bowel syndrome (IBS):
* Assessment: Reports intermittent abdominal pain and altered bowel habits.
* Likely Diagnosis: IBS.
* Rationale: Symptom history.
Plan:
* Discussed the need for an endoscopy to assess the oesophagus and stomach.
* Patient consented to gastroscopy.
* Advised on bowel preparation for gastroscopy.
* Will arrange gastroscopy for next month.
* Continue Omeprazole 20mg daily.
* Advised on lifestyle modifications including dietary changes and weight management.
* Follow-up in 4 weeks.
Yours sincerely,
Dr. Thomas Kelly
Letter to GP
Cc patient
Dear Doctor,
Thanks for your referral. I had the pleasure of seeing [patient name] today in my rooms.
Background:
[list all relevant medical conditions and diagnoses] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write as bullet points with one condition per line.)
[describe past surgical history in terms of abdominal operations] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write as bullet points.)
[describe details of past gastroscopy or colonoscopy and any relevant findings, or document 'no prior gastroscopy or colonoscopy' if patient has not had these procedures] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write as bullet points.)
[describe family history of gastrointestinal cancer, other cancers, IBD and coeliac disease, or mention absence of such family history if discussed] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write as bullet points.)
Medications:
[list current medications and herbal medications] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write on one line with a comma between each medication.)
Allergies:
[mention allergies] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write as a single line.)
Social history:
[describe social history, including living situation, occupation, independence of mobility, hobbies and social supports such as family and friends, smoking and alcohol history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write on the same line with a full stop after each point rather than separate bullet points.)
Progress:
[describe the patient's symptoms and presenting complaint, time course of symptoms, relieving and exacerbating factors, any treatments to date and their effectiveness, outline pertinent negatives, and other discussion points, specifically mentioning the presence or absence of dysphagia, odynophagia, reflux symptoms, indigestion/dyspepsia, vomiting, melaena, PR bleeding, change in bowel habits, unintentional loss of weight, fevers/rigors, change in appetite, or any history of iron deficiency with or without anaemia if mentioned] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write as a paragraph in full sentences, not as dot points. If the transcript discusses liver disease or abnormal LFTs, include the following points if mentioned: alcohol intake, body weight/BMI and metabolic disease, personal history of liver disease, family history of chronic liver disease including viral hepatitis/cirrhosis/HCC, risk factors for blood borne virus acquisition such as IVDU, high risk sexual activities, tattoos overseas, blood transfusions, ethnicity or place of birth.)
Examination:
[describe physical examination findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as bullet points.)
Investigations:
[describe the results from any tests or investigations, including the results of any blood or stool tests, using medical terminology where possible rather than layman's terms] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as bullet points.)
Active GI issues:
[list each active gastrointestinal issue or condition with assessment, including the likely diagnosis and rationale based on subjective and objective findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a numbered list with each issue as a separate numbered item, followed by bullet points for the assessment details.)
Plan:
[describe plan for gastroscopy and/or colonoscopy, including bowel preparation if outlined, and mention discussion around consent for procedures] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write as bullet points.)
[outline the other components of the management plan including any non-endoscopic investigations, treatments, referrals, and follow-up arrangements] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Write as bullet points.)
Yours sincerely,
[Clinician full name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit.)
(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 included 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.)
