Doctor writing patient notes on a medical examination or prescription
Dear Dr Smith,
I am referring to you a patient of mine, Mr Longman, 66 years old, for suspected heart disease. Mr Longman came to my surgery following a sudden unexpected syncope with no warning signs and no immediate outcome. The episode only lasted for a few moments.
Social history:
Retired joiner
Married, with 2 daughters Smoker
Medical / surgical history:
CABG five years ago
Current treatment:
Aspirin, ACE inhibitors, beta-blockers for 4 years
Family history:
Father died of MI at 60
Clinical examination:
Normal complexion
BP: 135/80; HR: 45 bpm
No palpitations, no murmur
Pulmonary examination: NAD
Neurological examination: Normal
Thank you in advance for attending to my patient.
I look forward to receiving your report.
Yours sincerely,
Dr Richard Thomson, MD
