Rheumatology Consult

Finished note

Example — generated by Notat from a sample visit

Reason for consultation:
Review of gradually worsening exertional breathlessness over two months. No chest pain at rest or syncope.

Assessment:
Stable clinical presentation requiring further outpatient evaluation.

Plan:
Arrange relevant investigations, continue current medicines, and advise urgent assessment for chest pain, fainting, or breathlessness at rest.

Clinical documentation:
Relevant symptoms, meaningful negatives, assessment, and follow-up advice were captured from the sample visit and organised into the selected template.

FactsContext™

Template

Rheumatology Consult

Date/Time:[Insert date and time of consult]

Reason for consult:[Insert brief statement of why rheumatology was consulted, who requested it, and specific question to be addressed]

Patient identification: [Insert patient name, age, gender, and a brief pertinent background]

History of present illness:
(Begin with the chief complaint and duration. Then provide a chronological, problem-oriented narrative that focuses on the reason for consultation. Group related symptoms into coherent separate paragraphs rather than a single block of text. For each main problem or symptom cluster, explicitly address where available: onset, duration, tempo/progression, location and radiation, quality, severity, aggravating and relieving factors, associated symptoms, and key negatives. Include relevant baseline function, prior episodes, relevant past investigations or imaging, prior treatments and response, and any recent triggers. Comment on relevant risk factors for the presenting problem when available. Summarize functional impact where available.  End with a review of systems related to the presenting problem)

[Paragraph 1]

[Paragraph 2]

[Review of systems specific to the speciality]

Past Medical History:
(Hyphenated list)

Medications:
(Hyphenated list)
- [Medication name, dose, route, frequency if mentioned]
- [e.g., Metformin 500 mg oral BID]

Allergies:
(Hyphenated list)
(If no known allergies, state exactly “No known drug allergies (NKDA)”)

Family History:
(Hyphenated list)
- [Relative]: [Condition or pertinent finding]
- [e.g., Mother: breast cancer]

Social History:
(Hyphenated list)
- Tobacco: [type, amount, duration, quit date if applicable]
- Alcohol: [type, amount, frequency]
- Recreational substances: [type, frequency]
- Occupation: [current job, exposures]
- Living situation: [who lives with patient, home environment]

Review of systems:
(hyphenated list)
- Constitutional: [e.g., fevers, weight loss]
- Musculoskeletal: [e.g., arthralgias, myalgias]
- Integumentary: [e.g., rashes, nodules]
- Respiratory, cardiovascular, GI, neuro, others as relevant

Physical examination:
(hyphenated list)
- Vital signs: HR #, BP #, T #, RR #, O2 sats #%
- General: [e.g., “Well‐appearing, in no acute distress”]
- Musculoskeletal: [e.g., joints examined, swelling, tenderness, range of motion, deformities—list each region or joint group separately]
- Skin: [e.g., rash description, nodules]
- Other systems as indicated

Investigations:
(hyphenated list)
- Labs: [e.g., ESR # mm/hr, CRP # mg/L, RF positive/negative, anti‐CCP #]
- Imaging: [e.g., X-ray hands—erosions noted; MRI elbows—synovitis]
- Other studies: [e.g., synovial fluid analysis]

Assessment & Plan:
(Use medical terminology if appropriate. Do not fabricate.)
[Insert concise one-sentence summary including age, sex, and key rheumatologic diagnosis or differential]

#) [Assessment as a numbered item] 
- [Hyphenated list with each corresponding plan item on a new line]