CONSULT NOTES
A good consult note contains the following elements, and should be prepared in this order:

HISTORY
ID and RFR (reason for referral)
• ID = Gender and age
• Include occupation and handedness if a hand consult
HPI
• Hand injuries: Mechanism, time of injury, any treatment so far
• Tetanus status if open wounds
PMHx
• Include PSHx (past surgical history)
Medications
• *Blood thinners*
SocHx
• Include smoking, EtOH, and recreational drug use (esp. IVDU)
Allergies
• Clarify the reaction to any stated allergy

PHYSICAL EXAMINATION

INVESTIGATIONS

ASSESSMENT AND PLAN

Example
ID 28M R-handed, works in construction
RFR Query flexor tenosynovitis
HPI 3d ago puncture wound to volar distal phalanx left index finger from drill bit. Reports pain locally and in palm x1 week. Similar episode hand pain 1 year ago without Hx trauma, resolved spontaneously. Denies fevers and chills. Tetanus UTD.
PMHx Healthy. Appendectomy @6yo
Meds None
SocHx Lives with girlfriend. Nonsmoker, no EtOH, no rec drug use
ALL None
O/E Looks well. BP 130/90, HR 75 bpm, RR12, SaO2 99% room air, afebrile.
R hand mildly swollen compared to L, mild palmar erythema. All digits NVI.
R index: swollen with 0.5 mm puncture wound mid DP radially, no purulence. Pain on passive extension but no tenderness over flexor sheath, no fusiform swelling, and digit held in neutral position.
Wound explored and irrigated in sterile conditions under local anaesthesia: maximal wound depth is to subcutaneous tissue only
Ix WBC 6.0
XR R hand: normal
A+P Inconsistent with flexor tenosynovitis as wound not adjacent to flexor sheath and pain began before injury.
Likely tenosynovitis given previous episode with spontaneous recovery.
Rx given for Naproxen x1 week. F/U Dr. X in 1 week, or call office if worsening or becomes unwell.