Dr D Kurac (name of doctor you are referring the patient to)
Surgeon
Weight center (address)
393 Victorian Road
Richmond, Melbourne
15 June 2018 (Date – format doesn’t matter)
Dear Dr Kurac (Dear name of doctor.)
Re: Andy Williams, aged 65 years old (Re: patient and age /
DOB. If age and DOB are both given, write DOB instead)
Paragraph one:
Patient / Condition / Purpose – formats are more or less fixed for all
referral letters
Patient – Andy
Williams. Condition – obesity. Purpose - Evaluation of obesity and recommendation for treatment (but in paragraph
1, lets keep it brief – evaluation and treatment. We will save the details -
Evaluation of obesity, recommendation for treatment for the last paragraph aka
request)
ü
I am referring Andy Williams (*Patient), who has been
suffering from obesity (*Condition), to you for evaluation and treatment (*Purpose)
ü
I am writing to refer Andy Williams (*Patient) to you. He has
been suffering from obesity (*Condition). Your evaluation and treatment (*Purpose) would be highly appreciative.
ü
Thankyou for seeing Andy Williams (*Patient), who has been suffering from obesity (*Condition). for evaluation and
treatment (*Purpose)
Paragraph 2
Details: 163
cm, 155.5 kg, BMI 46.6, family history of obesity, medical history (type 2
diabetes, hypertension, sleep apnea, BG levels 100-130 mg/dl, triglycerides 201
mg/dl, serum insulin insulin 19 IU/ml). Medications (30 and 70 units of NPH
insulin before breakfast / before or after dinner, 850 mg metformin twice
daily, atorvastatin, lisinopril and nifedipine)
Mr Williams has a family
history of obesity. He weighs 155.5 kg and his BMI is around 46.6 kg/m2. He
presents with diabetes, hypertension and sleep apnea. Lab reports showed
(revealed) that his blood glucose was within 100-130 mg/dl and serum insulin
and triglycerides were 19 IU/ml and 201 mg/dl respectively. His medications
included 30 and 70 units of NPH insulin before breakfast / before or after
dinner, 850 mg metformin twice daily, atorvastatin, lisinopril and nifedipine.
Paragraph 3
Details: Childhood obesity, gains weight every decade, at highest adult weight, participated in commercial and medical weight loss programs, consulted registered dietician,
Mr Williams has been suffering from obesity since he was a child. He participated in various weight loss programs and even consulted a dietitian. However, these failed to tackle his obesity problem (failed to reduce his weight to an acceptable range)
*Alternatively, it might be
better to combine: family history of obesity, weighs 155.5 kg, childhood
obesity together into one paragraph and diabetes / hypertension, lab reports,
medications into one paragraph
Paragraph 2
Mr Williams has a family
history of obesity. He has been suffering from obesity since childhood. Despite
participating in various weight loss programs and consulting a dietitian, he
continues to put on weight and currently weighs 155.5 kg with a BMI of 46.6 kg
/ m2.
Paragraph 3
Mr Williams presents with
diabetes, hypertension and sleep apnea, for which he is taking 30 and 70 units
of NPH insulin before breakfast / before or after dinner, 850 mg metformin
twice daily, atorvastatin, lisinopril and nifedipine. Lab reports showed that
his blood glucose fell within 100-130 mg/dl and serum insulin and triglycerides
were 19 IU/ml and 201 mg/dl respectively.
Paragraph 4 Details: Diet - 3 meals / day. Reports limited fast food consumption 2
nights / weeks, no alcohol, reports binge eating triggered by stress，plan - Concerned
about health / wants to get life under control, wants to learn about surgical
options, partner encouraging.
Mr Williams eats 3 regular
meals per day. He limits fast food consumption and doesn’t drink any alcohol. However,
he claims (reports / said that) to binge eat occasionally due to stress. He has
the support of his partner and is considering surgical treatments that may help
him get his weight and general health under control.
Paragrah 5 - Request: more or less the same format for all referral letters -
In
the view of above, kindly evaluate ……
Details - Evaluation of obesity, recommendation for
treatment
In the view of above, kindly evaluate Mr William’s condition and suggest him the
most appropriate treatment regime. Should you have any questions, please do not
hesitate to contact me.
Dr Ian Robson
Allergist
Central Hospital Oldtown
17/06/18
Dear Dr Robson
Re: Mr Tom Riddle (DOB: 19/05/08)
Paragraph one
I am referring Mr Riddle, who is presenting with asthmatic
symptoms, to you for further testing and identification of his allergies.
Paragraph 2
Details: family
history of asthma, childhood asthma – nil episodes 8 years, eczema (periodic),
no known allergies
Mr Riddle has a family history of asthma. He was diagnosed
with childhood asthma, which was well controlled for the past 8 years (which
didn’t show any symptoms for the past 8 years). He has eczema but no known
allergies.
Paragraph 3:
Details:
1/6/18 - 2 weeks breathlessness “needs to sit up”,
persistent coughing / wheezing, eyes itching, missing classes. Notes: new accommodation – two cats,
dusty old carpet, sleeps on floor
2/6/18 – CXR clear, Pre-bronchodilator – FEV1: 3.61,
Post-bronchodilator – FEV1: 4.35, response positive – 20%. Diagnosis: asthma, Plan: oral
prednisolone 50 mg – 10 days, albuterol inhaler,
Mr Riddle presented at my clinic on 1/6/18. He complained
about breathlessness for 2 weeks, persistent coughing and itchy eyes, which resulted
in his absence from college. He also mentioned that he moved into a new
accommodation where he had two cats, a dusty old carpet and slept on the floor.
In the subsequent visit on 2/6/18 (*Too long winded, we can simply use “1 month later”), Mr Riddle’s
Pre-bronchodilator – FEV1: 3.61, Post-bronchodilator – FEV1: 4.35, and response
positive – 20% indicated that he had asthma (showed that he was diagnosed with
asthma), and for that, I administered him with oral prednisolone (*omit 50 mg –
10 days. Such details aren’t necessary) and albuterol inhaler.
*?? Perhaps it might be alright if I made the following
alterations: 1 month later, Mr Riddle’s Pre-bronchodilator and
post-bronchodilator values and response positive percentage indicated an asthma
episode, which was treated with oral prednisolone and albuterol inhaler.
Paragraph 4
Details: 14/6/18
- sleep disruption, albuterol
increased, eczema flare, vitals (BP, pulse, respiratory rate) above normal
levels, Oxygen saturation and PaO2 below normal level. Auscultation –
bilaterally diminished lung sounds, expiratory wheezing, administered oxygen
3L, attained O2 sat 93%, albuterol hourly, IV corticosteroid – positive
response. 17/8/18 – discussed environmental triggers, proper inhaler technique
On 14/6/18, he presented with sleep difficulties and eczema.
His blood pressure, pulse respiratory rate were above normal levels, whereas,
his oxygen saturation and PaO2 were below normal levels. Auscultations revealed
diminished lung sounds and expiratory wheezing. 3L of oxygen, albuterol
(hourly) and IV corticosteroid were administered. 2 months later, I educated
him about environmental triggers and proper inhaler technique.
*Alternatively, we can omit details such as: “His vitals
such as: blood pressure, pulse respiratory rate were above normal levels,
whereas, his oxygen saturation and PaO2 were below normal levels.” Because 3 L
of oxygen, albuterol and IV corticosteroid managed to deal with them.
Modified answer: on
14/6/18, he presented with sleep difficulties and eczema. His vitals such as
blood pressure, oxygen saturation, were not within normal levels. Diminished
lung sounds and expiratory wheezing were heard during auscultation. Oxygen,
hourly albuterol and IV corticosteroid were administered. On subsequent visits,
I educated him on environmental triggers and proper inhaler technique.
So: Model answer: Twelve
days later, he presented again with an acute exacerbation of bronchial asthma
that was treated with oxygen, hourly albuterol and intravenous corticosteroids.
Subsequent to this visit, he was educated about possible environmental triggers
and proper inhaler technique.
Paragraph 5:
Details: further
testing and identification of his allergies, provide guidance on environmental
management.
In view of the above, kindly conduct the necessary
allergenic tests and provide guidance on environmental management. Should you
have any questions, please do not hesitate to contact me.