Anamnesis

Patient: [Occupational history and age including years on job, previous occupations, part-time or full-time status, characteristics of job such as desk-based or hands-on work, physical effort associated, strain patterns, and ergonomic factors] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Presenting complaint:** [Description of current symptoms including onset, duration, intensity, and character of pain or discomfort] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Detailed history of presenting complaint noting specific movements, activities, or circumstances that aggravate or alleviate symptoms] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Previous history of similar presentations] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Associated symptoms or complaints that patient believes may be related] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Restricted activities and impact on patient's daily life] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Other complaints] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **General health:** [Patient's self-assessment of health status and reasoning] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Current medications including dosage and indication] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Exercise routines including frequency, intensity, and results] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Diet habits including restrictions, supplements, and impacts] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Sleeping habits including interruptions, effects of presenting complaint, level of rest, and energy levels] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Smoking and drinking habits] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Medical conditions patient currently experiences] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a diagnosis.) **Past medical history:** [Serious illnesses including hospitalisations] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Previous operations] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Road traffic accidents, major falls, or injuries including fractures] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Medical investigations] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Family medical conditions and history including genetic predispositions and risk factors] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Systemic inquiry:** [Cardiovascular and respiratory systems including shortness of breath on exertion, chest, arm, or facial unexplained dull pain, palpitations, blood pressure issues, recurrent chest infections, persistent cough, and wheezing] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Gastrointestinal system including reflux, indigestion, constipation, diarrhoea, irritable bowel syndrome, and aggravating or relieving factors] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Neurological symptoms including headaches, dizziness, diplopia, dysarthria, dysphagia, drop attacks, nystagmus, nausea, and numbness] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Urological system including bladder function, prostate tests, micturition changes, nocturia, and associated pain] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Gynaecological system including bladder function, menstruation changes, menopausal changes, regular smear tests, and breast examinations] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Pregnancies including voluntary or involuntary interruptions, type of delivery, anaesthesia, equipment used, and complications] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Any other relevant information [Any other relevant additional information] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Initial Assessment:** [Vitals including blood pressure, heart rate, respiratory rate, temperature] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Physical examination findings focusing on structural assessment, palpation of musculoskeletal system for areas of tension, misalignment, or restricted movement, evaluation of posture, mobility, and gait] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Neurological examination including reflexes, sensory testing, and motor strength] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [General medical screening including abdominal, thoracic, and cervical medical assessment] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Orthopaedic examination of relevant regions] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Diagnostic tests ordered or reviewed such as X-rays, MRIs, or laboratory tests pertinent to osteopathic evaluation] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) _Osteopathic considerations:_ [Osteopathic diagnosis or assessment of patient's condition integrating findings from subjective and objective evaluations] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a diagnosis.) [Identification of key areas for osteopathic treatment including somatic dysfunctions and their potential impact on overall health] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Working diagnosis:** [Allopathic diagnosis relevant for initial presentation including associated somatic dysfunctions and muscle restrictions, segmental restrictions that influence local presentation, and lifestyle and occupation factors relevant to overall postural pattern] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a diagnosis.) **Treatment plan:** [Detailed treatment plan outlining osteopathic manipulative treatment techniques to be employed such as soft tissue techniques, myofascial release, high-velocity low-amplitude thrusts] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Expected frequency and duration of treatment sessions] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Short-term and long-term goals of treatment including specific outcomes such as pain relief, improved mobility, and enhanced overall well-being] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Advice on lifestyle modifications, exercises, or ergonomic changes to support treatment outcomes] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Plans for additional diagnostics or referrals to other healthcare professionals] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Treatment performed:** [Details of osteopathic manipulative treatment techniques and therapeutic interventions applied during the session] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Immediate response to treatment and any changes in symptoms or function observed] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Post-treatment Assessment:** [Assessment of progress towards treatment goals based on patient feedback and clinical findings] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Adjustments to treatment plan based on evaluation of progress] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Additional Notes: [Educational information provided to patient on managing symptoms, preventing injury, or improving health and wellness] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Specific instructions for home care, exercises, or follow-up activities] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Patient concerns or preferences discussed during the visit] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Ongoing informed consent during the visit] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Informed consent to perform high-velocity techniques] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Consent to use Scribe during the visit] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) (Only summarise and reformat information provided in the transcript, contextual notes, or clinical note. Do not generate new diagnoses, assessments, treatment plans, or clinical recommendations. Do not invent patient details, examination findings, medical history, or professional judgements. If information for a section is not mentioned, omit that section completely. Write in a clear, professional osteopathic clinical tone.)