Neurosurgeon's note

- [Consultation date] - [Patient’s name (SURNAME Firstname) (and name of partner / next of kin / friend)] - [Name of referring doctor] - [New patient or Follow-up] - [Diagnosis, ICD-10] - [Surgery discription and Date of surgery/ intervention] [Age] [Gender] Subjective: - [Reason(s) for consultation, including specific surgical concerns or symptoms related to previous surgery.] (Only include reason for consultation and specific surgical concerns or symptoms if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - [Detailed history of the presenting complaint(s), including duration, severity, aggravating/alleviating factors, associated symptoms, nature, any previous treatments and responses.] (Only include detailed history of presenting complaints if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - [Past medical and surgical history, highlighting previous surgeries, hospitalizations, outcomes.] (Only include past medical and surgical history if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - [Current medications, including any anticoagulants, pain management, or antibiotics.] (Only include current medications if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - [Social history, focusing on tobacco, alcohol use, and occupation, given their relevance to surgical risks and recovery.] (Only include social history if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - [Allergies, including allergies to medications, latex, or materials used in surgical procedures.] (Only include allergies if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Objective: - [Vital signs including Blood Pressure, Heart Rate, Temperature, Oxygen Saturation, etc..] (Only include vital signs if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - [Physical examination findings, with emphasis on areas relevant to surgical assessment, including inspection, palpation, percussion, and auscultation findings.] (Only include physical examination findings if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - [System-specific examination relevant to the surgical concern, e.g., abdominal examination for appendicitis.] (Only include system-specific examination findings if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - [Investigation results, including imaging and laboratory tests pertinent to surgical assessment with dates where possible] (Only include investigation results if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Assessment & Plan: [1. Surgical Issue or Condition] - [Assessment, including the likely diagnosis and rationale based on subjective and objective findings.] (Only include assessment and rationale if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - [Differential diagnosis, considering other potential surgical or medical conditions.] (Only include differential diagnosis if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - [Investigations planned, specifying any additional imaging or tests needed for a definitive diagnosis or pre-operative planning.] (Only include investigations planned if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - [Surgical treatment planned, detailing the type of procedure, expected outcomes, and potential risks.] (Only include surgical treatment plan if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - [Pre-operative preparation, including any necessary lifestyle modifications, pre-medication, and fasting instructions.] (Only include pre-operative preparation if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - [Post-operative care plan, covering expected hospital stay, pain management, wound care, and follow-up appointments.] (Only include post-operative care plan if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - [Relevant referrals, for multidisciplinary care or further evaluation if needed.] (Only include relevant referrals if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) (Never come up with your own assessment or plan. Always use the transcript or contextual notes provided for this section.) [2. Additional Surgical Issues or Conditions] - [Follow the same structure as above for each additional issue or condition identified.] (Only include additional surgical issues or conditions if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) (Never come up with your own assessment or plan, always use the transcript or contextual notes provided.) [Additional Notes:] - [Patient education and informed consent, including discussion of the procedure, potential risks, benefits, and alternatives.] (Only include patient education and informed consent if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - [Instructions for emergency care or signs to watch for post-operation.] (Only include emergency care instructions if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - [Any specific patient or family concerns addressed during the consultation.] (Only include specific patient or family concerns if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely. Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)