Anamnèse classique urgences

**Plainte principale:** [Description of the primary reason for the consultation, including duration, in one sentence] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) **Histoire de l'affection actuelle:** [Provide a detailed narrative of symptoms and relevant history, including pertinent negatives, risk factors, and exposure] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) [Describe any previous occurrences of current symptoms or issues, including recent visits, assessments, hospital admissions in the last year] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) [Describe related visits, investigations, management, and any diagnoses] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) [Include medications taken and the patient’s response] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) [Associated symptoms] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) [Other relevant history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) **Revue des systèmes:** - Général: [Weight change, Fever, Chills, Night sweats, Fatigue, Malaise] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) - Yeux: [Eye pain, Swelling, Redness, Foreign body sensation, Discharge, Vision changes] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) - Oreilles, Nez, Bouche, Pharynx: [Hearing changes, Ear pain, Nasal congestion, Sinus pain, Hoarseness, Sore throat, Rhinorrhea, Swallowing difficulty] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) - Cardiovasculaire: [Chest pain, SOB, PND, Dyspnea on exertion, Orthopnea, Claudication, Edema, Palpitations] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) - Respiratoire: [Cough, Sputum production, Wheezing, Smoke exposure, Dyspnea] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) - Gastrointestinal: [Nausea, Vomiting, Diarrhea, Constipation, Abdominal pain, Heartburn, Dysphagia, Hematochezia, Melena, Jaundice] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) - Génitourinaire: [Dysuria, Urinary frequency, Hematuria, Urinary incontinence, Flank pain, Changes in urinary flow] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) - Musculosquelettique: [Arthralgias, Myalgias, Joint swelling, Back pain, Neck pain] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) - Téguments: [Skin lesions, Pruritis, Hair changes, Nipple discharge] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) - Neurologique: [Weakness, Numbness, Paresthesias, Syncope, Dizziness, Headache] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) - Psychiatrique: [Anxiety, Depression, Insomnia, Delusions, Suicidal ideation, Hallucinations] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) - Endocrien: [Polyuria, Polydipsia, Temperature intolerance] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) - Hématologique/Lymphatique: [Bruising, Bleeding, Transfusion history, Lymphadenopathy] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) - Allergique/Immunologique: [Allergic reactions, Auto-immune disorders] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) **Antécédents (non exhaustif):** [List of past medical conditions] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) [Social history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) [Family history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) [Social history including smoking, alcohol consumption, and drug use habits] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) **Traitements (non exhaustif):** [Current medications; include source of information, especially if from electronic record] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) **Allergies:** [Any allergies and associated reactions] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) **Examen physique:** - Apparence: [Brief description of general appearance] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) - Signes vitaux: [Record temperature, blood pressure, heart rate, respiratory rate, glucose levels, oxygen saturation, and any other vital signs mentioned] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) - TYONG: [Findings related to head, eyes, ears, nose, and throat] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) - Respiratoire: [Findings related to the respiratory system, such as air entry, crackles, or wheezes] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) - Cardiaque: [Findings related to the cardiovascular system, such as heart sounds, murmurs] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) - Abdominal: [Findings from palpation, tenderness] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) - Musculosquelettique: [Findings related to the musculoskeletal system, such as joint swelling, bruises] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) - Peau et téguments: [Findings related to skin, including rashes, open wounds (size, shape, depth if mentioned)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) - Autre: [Any other physical exam findings, if mentioned] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) **Investigations:** [Results of basic blood work] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) [Results of any imaging] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) [ECG findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) **Plan/Proposition thérapeutique:** [Most likely diagnosis and differential diagnoses suggested by the physician, as well as the overall plan for further assessment, diagnosis, and management in the emergency department and post-discharge] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) [Recommended medications and dosage] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) [General patient care advice] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) [Danger signs that would prompt a return to the emergency department] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) [Follow-up recommendations] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) **Suivi en externe:** [List any elements specifically identified by the physician for follow-up by the patient's usual primary care provider, in point form] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) **Diagnostic(s)/Hypothèse(s) diagnostique(s):** [Differentiate whether it is a final diagnosis or working diagnosis] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) [Primary diagnosis] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) (For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, diagnosis, interventions, evaluation or 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, do not state that it was not mentioned; simply leave the relevant placeholder or section blank. Use as many lines, paragraphs or bullet points as needed to capture all relevant information from the transcript.)