Dear Mrs. Davies
It was a pleasure to meet you today at the Colorectal Surgery Clinic.
Your presenting complaint is a 3-month history of intermittent rectal bleeding, described as bright red blood mixed with stool, occurring approximately 2-3 times per week. You also report a change in bowel habits, specifically increased stool frequency and a sense of incomplete evacuation for the past 6 weeks. There has been no significant weight loss or abdominal pain.
You previously underwent a flexible sigmoidoscopy 2 years ago, which revealed internal haemorrhoids, but no other pathology. Your past medical history is significant for well-controlled hypertension managed with Ramipril. There is no family history of bowel cancer.
Physical examination today revealed no palpable abdominal masses. Digital rectal examination identified grade II internal haemorrhoids, but no palpable masses or tenderness. There was no perianal pathology noted.
To summarise, your symptoms of rectal bleeding and altered bowel habits are concerning and warrant further investigation to exclude serious diagnoses, particularly given your age. While haemorrhoids are a common cause of rectal bleeding, a change in bowel habit necessitates a thorough evaluation.
We will proceed with a colonoscopy to thoroughly examine your large bowel. This will help us identify the cause of your symptoms and guide appropriate management. My secretary will contact you shortly to arrange a convenient appointment. We will review the findings once the procedure has been completed.
Thank you for your trust in allowing me to be part of your care.
Summary:
- 3-month history of intermittent rectal bleeding and 6 weeks of altered bowel habits.
- Colonoscopy to be arranged to investigate symptoms.
With kind regards,
Dr. Benjamin Carter
Consultant Colorectal Surgeon
Secretary: Ms. Sarah Jenkins, sarah.jenkins@colorectalsurgery.com
(Write in a formal, professional, and concise tone, while remaining patient-friendly. Write in the first person from the clinician's perspective. Summarise key information rather than providing a verbose recap of the conversation. Get straight to the point. Be direct and avoid conversational filler phrases. Present information in shorter, focused paragraphs.)
Dear [Patient's title and last name] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else use an appropriate title and omit the last name.)
It was a pleasure to meet you today [in the clinic name if stated]. (Only include the clinic name if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit the clinic name and write the sentence without it.) [The names and roles of any additional people present at the consultation] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this sentence entirely. Write concisely as a full sentence.)
(The following four placeholders should be combined into concise, focused paragraphs that summarise the key clinical information. Do not use conversational lead-ins. Omit minor details unless critical.)
[The patient's presenting complaint and key symptoms including their duration and relevant positive and negative findings] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Summarise concisely in a brief paragraph.)
[A summary of previous investigation results and relevant past medical history including key investigation findings, relevant past procedures, and major pre-existing conditions. Omit non-critical details unless directly relevant] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Summarise concisely in a brief paragraph.)
[A summary of the key physical examination findings] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Summarise concisely in a single paragraph.)
[A brief clinical impression and summary for the patient, including the clinical concern, the reason for further investigation, potential serious diagnoses being considered, and other possibilities] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Never invent or infer a diagnosis. Begin with a phrase such as "To summarise..." and write as a concise paragraph.)
[The proposed treatment and investigation plan including the names of tests ordered, their purpose in simple terms, and follow-up arrangements] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write concisely in a brief paragraph.)
"Thank you for your trust in allowing me to be part of your care."
Summary:
[A concise bullet point summary of the presenting complaint] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this bullet point entirely. Present as a single bullet point.)
[A concise bullet point summary of the proposed plan] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this bullet point entirely. Present as a single bullet point.)
"With kind regards,"
[Clinician's full name] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write on a single line.)
[Clinician's job title] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write on a single line.)
[Secretary or administrative contact details including name and email address] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write each contact on a separate line.)
