The referral letter and the reply letter

When a GP/ family doctor refers a patient to a consultant, he/she will write a letter of referral, on the doctor's headed paper, in which details are given about the patient's presenting complaint, medical history, family history, clinical findings, test results, and prior treatment so that the consultant has as much information as possible to provide the appropriate care. Such letters should be structured clearly with headings so that the consultant will find the relevant information easily.
The expressions highlighted in the letter below are standard and can be used almost systematically in this type of letter.

Dr Albert Winterbottom, MDMD = Doctor of Medicine
25 Sycamore road
Warrington WA1
Cheshire

22 July, 2012

Dr Henry Wolf, MD
11 Owens Park Drive
Manchester M14

Dear Dr Wolf,

I am referring toto refer a patient to another doctor = to send him/her to another doctor (usually a specialist / consultant), hence the expression a referral letter. you a patient of mine, Mr Truman, 75 years old, for suspected heart disease.
Mr Truman came to my surgerya surgery = a place where a general practitioner or a dentist practices (as opposed to surgery = an operation, a surgical procedure). following a sudden unexpected syncope with no warning signs and no immediate sequellae. The episode only lasted for a few moments.

Social history:
Retired bus driver
Married, with 3 sons living locally
Current smoker

Medical / surgical history:
CABGCABG = Coronary Artery Bypass Graft five years ago

Current treatment:
Aspirin, ACE inhibitors, beta-blockers for 5 years

Family history:
Father died of MIMI = myocardial infarction at 60

Clinical examination:
Normal complexion
BP: 130/80; HR: 45bpm
No palpitations, no murmur
Pulmonary examination: NADNAD = Nothing Abnormal Detected
Neurological examination: Normal

Thank you in advance for attending toto attend to a patient = to look after / to take care of a patient my patient.
I look forward to receiving your report.

Yours sincerely,

Dr Albert Winterbottom, MD

 

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