Specialist to specialist letter template
The reply to the colleague who referred, at a specialist reading level.
- Clinical question on referral
- Restated.
- Findings
- Examination and investigations.
- Impression
- Differential and working diagnosis.
- Plan
- Investigations ordered, treatment commenced, follow-up agreed.
Worked examples
Specialist letter · valve surveillance Matthews, Colin · 66M · Synthetic patient
Clinical question on referral Assessment of a systolic murmur found before elective hernia repair. Findings Transthoracic echocardiogram shows a trileaflet aortic valve with peak velocity 3.8 m/s, mean gradient 34 mmHg and valve area 1.2 cm². Left ventricular function preserved with no hypertrophy. Exercise tolerance unlimited on direct questioning. Impression Moderate aortic stenosis, asymptomatic. Plan Surveillance TTE in 12 months. Advised to report exertional chest pain, breathlessness or syncope. No contraindication to the planned hernia repair under a standard anaesthetic.
Specialist letter · interstitial lung disease Gray, Robert · 71M · Synthetic patient
Clinical question on referral Cause of a restrictive pattern with reduced transfer factor in a former boilermaker. Findings HRCT: basal, subpleural reticulation with traction bronchiectasis, no honeycombing, no pleural plaques. FVC 68% predicted, DLCO 52% predicted. Autoimmune serology negative. 6MWT 420 m, nadir SpO2 91%. Impression Probable UIP pattern. Asbestos exposure as a boilermaker; asbestosis remains in the differential and is relevant to any claim. Plan Discussed at the interstitial lung disease multidisciplinary meeting on 12 August. Antifibrotic therapy to start once baseline liver function is confirmed. Pulmonary rehabilitation referred. Repeat lung function in three months.
