Surgical Consultation and Assessment Note

Surgical Consultation and Assessment Note Referral Reason and Presenting Complaint: [document the reason for referral, symptoms, duration, progression, and previous treatments attempted. Include referrals from primary health clinics, district hospitals, or private GPs if relevant. Note symptom evolution such as pain, swelling, or impaired function and any initial management such as analgesia or physiotherapy] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Relevant History: [include past medical and surgical history including conditions like hypertension, HIV, TB, diabetes, or previous procedures at state or private hospitals. Include family history (if relevant to surgical risk), medication list (including ART or chronic meds), known allergies, and social history such as tobacco/alcohol use, housing, or type of employment (e.g. physical/manual labour, domestic work)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Clinical Examination Findings: [record physical findings relevant to surgical assessment such as site-specific tenderness, swelling, hernias, masses, neurological signs, limb function, or wound characteristics. Include any observations made during outpatient clinic or bedside assessment] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Investigations Reviewed or Ordered: [summarise reviewed X-rays, ultrasounds, blood work, or referrals for additional imaging or specialist review. Include context such as public hospital radiology, NHLS labs, or point-of-care testing done during clinic visit] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Impression and Differential Diagnosis: [document working diagnosis and alternate considerations based on findings. Include diagnostic certainty, suspected pathology (e.g. abscess, bowel obstruction, malignancy), and relevance to surgical candidacy] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Management Plan: [outline next steps including referral for surgery at higher level of care (e.g. regional/tertiary hospital), surgical listing, additional investigations (e.g. CT scan), conservative management (e.g. wound care), or patient education. Include follow-up timing or referrals for social support if applicable] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) (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 as needed to capture all the relevant information from the transcript.)