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Purpose — New / Suspected Diagnosis
Formula: I am writing to refer + patient + for + assessment and management of + condition.
Example: I am writing to refer Mr Brett Collister for assessment and management of suspected Type 2 diabetes mellitus.
Purpose — Specialist / Surgical Referral
: I am writing to refer + patient + for + specialist consultation + regarding + condition/procedure.
Example: I am writing to refer Mrs Carol Potter for a surgical consultation regarding her severe left knee osteoarthritis and suitability for left knee joint replacement.
Current Presentation — Symptoms + Duration
On + date, patient + presented with + symptoms, which had been present for + duration.
Example: On 4 February, Mr Collister presented with tiredness, sore eyes and occasional dizziness, which had been present for approximately three to four weeks.
Persistent / Worsening Symptoms at Follow-up
At his/her subsequent review, + symptoms + persisted, with + new/worsening symptom.
Example: At his subsequent review, his tiredness and sore eyes persisted, with worsening vision.
Duration + Progressive Symptom
Formula: Patient + has experienced + increasing/worsening + symptom + over the past + duration.
Example: She has experienced increasing left-knee pain when walking over the past 12 months.
Severity Despite Treatment
Back:
Formula: The symptom + has become + severity + despite + treatment.
Example: The pain has become severe despite regular Panadol Osteo.
Additional Symptom Pattern
Patient + also experiences + symptom + at rest/following + trigger.
Example: She also experiences pain at rest following a long walk
Functional Impact
Symptom + has resulted in increasing difficulty + -ing.
Example: Her knee pain has resulted in increasing difficulty walking.
Relevant Chronic History
Patient + has a history of + condition + affecting/involving + body area.
Example: She has a history of osteoarthritis, mainly affecting both hands and knees.
Additional Medical History
Formula: His/Her medical history also includes + condition.
Example: Her medical history also includes well-controlled hypertension.
BMI + Category
Formula: Patient + is/remains + BMI category, with a BMI of + value.
Example: He remains overweight, with a BMI of 28.4 kg/m².
Lifestyle Advice
Formula: Patient + was advised regarding + lifestyle change.
Alternative: Patient + was advised to + verb.
Example: He was advised regarding weight loss and exercise.
Failure to Modify Lifestyle
Despite previous advice, patient + had made no changes to + lifestyle/diet/exercise.
Example: Despite previous advice, he had made no changes to his lifestyle, diet or exercise.
Negative History
There is no history of + event/risk factor.
Example: There is no history of recent injury.
Absent Symptoms
Patient + reports no + symptoms.
Example: She reports no swelling or redness.
Examination Findings
Formula: On examination, + findings + were noted, with + additional/negative finding.
Example: On examination, reduced range of movement and joint-line tenderness were noted, with no swelling.
Examination Findings — Alternative
The examination revealed + findings, with + relevant negative finding.
Example: The examination revealed reduced range of movement due to pain and joint-line tenderness, with no swelling.
Investigation — Two Results with Respectively
Formula: Investigation + revealed + finding A and finding B + values X and Y, respectively.
Example: Blood tests revealed random and fasting glucose levels of 13.5 and 7.4 mmol/L, respectively.
Investigation — Add Another Finding
a: Investigation + revealed + main findings, together with + additional finding.
Example: Blood tests revealed random and fasting glucose levels of 13.5 and 7.4 mmol/L, respectively, together with an HbA1c of 8.5%.
Investigation → Diagnosis
These results indicate + diagnosis.
Alternative: These results are suggestive of + diagnosis.
Alternative: These results are consistent with + diagnosis.
Example: These results indicate Type 2 diabetes mellitus.
Investigation → Diagnosis + Specific Findings
Formula: Investigation + revealed/demonstrated + diagnosis, with + specific findings.
Example: The X-ray revealed severe osteoarthritis, with osteophyte formation and loss of joint space.
Investigation → Diagnosis Characterised by Findings
Formula: Investigation + revealed + diagnosis, characterised by + findings.
Example: The X-ray revealed severe osteoarthritis, characterised by osteophyte formation and loss of joint space.
Current Management
Formula: Medication + was prescribed, and + other treatment + was arranged.
Example: Naproxen 250 mg twice daily was prescribed, and physiotherapy was arranged.
Final Request — Assessment + Recommendations
I would appreciate your assessment of + patient + and recommendations regarding + future management.
Example: I would appreciate your assessment of Mr Collister and recommendations regarding the future management of his suspected Type 2 diabetes mellitus.
Final Request — Suitability for Procedure
I would appreciate your assessment regarding the suitability of + procedure/treatment + for + patient.
Example: I would appreciate your assessment regarding the suitability of a left knee joint replacement for Mrs Potter.
Suitability for a Procedure
Formula: suitability for + procedure
Examples: suitability for surgery / suitability for knee replacement / suitability for bariatric surgery
No Known Drug Allergies
Formula: Patient + has no known drug allergies.
Example: She has no known drug allergies.
Follow-up Introductory Phrase
Formula: Introductory phrase + comma + main clause.
Examples: At his subsequent review, … / On examination, … / Following discharge, …
Symptoms Present for a Duration
Formula: Symptoms + had been present for + duration.
Example: His symptoms had been present for approximately three to four weeks.
Management of a Condition — Preposition
Formula: management of + condition
Examples: management of diabetes / management of chronic pain
Avoid: management for diabetes
Assessment of vs Suitability for
suitability for + procedure
Example: assessment of Mrs Potter / suitability for knee replacement