Letter to Referrer
Created by
Riaan Venter
Specialty
Neurosurgeon
Last edited
10/20/2026
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0 times
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About this template
A reusable letter structure for updating a referring clinician about a patient's assessment, relevant history, findings, and care plan. It supports clear communication and continuity of specialist care.
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Dear Dr Thabo Mbeki,
I am writing to update you about Mr Sipho Ndlovu (DOB: 12/05/1968, ID: 6805125123081), who was referred for refractory hypertension and suboptimal T2DM control.
Mr Sipho Ndlovu attended with persistent headaches, mild exertional SOB, and home BP readings averaging 165/95 mmHg over the past 4 weeks. He reports good medication adherence and denies chest pain, orthopnoea, or visual disturbances.
The assessment identified the following: BP 168/96 mmHg, HR 78 bpm regular, BMI 31.2 kg/m², dual heart sounds with no murmurs, chest clear to auscultation, and trace bilateral pedal oedema, ECG showing sinus rhythm with LVH criteria, HbA1c 8.6 %, eGFR 58 mL/min/1.73m², creatinine 118 µmol/L, and urine ACR 6.2 mg/mmol.
Relevant medical history: T2DM (diagnosed 2016), essential hypertension, dyslipidaemia, and laparoscopic cholecystectomy (2019).
Current medicines and supplements: metformin (Glucophage®) 1,000 mg PO BID, amlodipine (Norvasc®) 10 mg PO OD, atorvastatin (Lipitor®) 20 mg PO nocte, and over-the-counter omega-3 fish oil 1,000 mg PO OD.
Allergies: penicillin (maculopapular rash).
Social history: non-smoker, consumes 4 units of alcohol per week, works as a high school principal, lives with his wife, and has a sedentary lifestyle with high dietary sodium intake.
Following the assessment, the plan is: initiate perindopril (Coversyl®) 4 mg PO OD and dapagliflozin (Forxiga®) 10 mg PO OD, continue current regimen, advise a low-sodium diabetic diet with 30 minutes of daily brisk walking, check U&E in 2 weeks to monitor renal function, and review in clinic in 6 weeks with a home BP diary.
I will continue to review Mr Sipho Ndlovu and will send further updates when appropriate. Please contact me if you need additional information or wish to discuss any particular concerns.
Thank you for referring this patient and for working collaboratively in their care.
Yours sincerely,
Dr Pieter van der Merwe Internal Medicine Specialist Netcare Milpark Hospital, Suite 204, Guild Road, Parktown West, Johannesburg, 2193 | Tel: 011 480 5600 | Email: pvandermerwe@milparkmed.co.za | MP: 0458921
How to use this template
This template can be used to assist with various tasks in the medical field. You can use it to generate notes, manage patient information, or assist with diagnosis and the Assessment and Plan. To use this template, simply click the “Use Template” button above. If you have any questions or need assistance, feel free to reach out to the support team or refer to the description and example output provided above.