**History**
• URTI
• IHD
• HTN
# **URTI**
- Onset 3 days ago, following exposure to child with cough.
- Main sx: Sore throat, rhinorrhoea, cough. Associated features: Mild fever, myalgia.
- Known dx or relevant hx: Nil.
- Investigations performed to date: Nil.
- Prev tx: Paracetamol.
# **IHD**
- Onset 10 years ago.
- Main sx: Occasional chest pain on exertion.
- Known dx or relevant hx: Angina.
- Investigations performed to date: ECG, stress test.
- Prev tx: Aspirin, statin.
# **HTN**
- Onset 5 years ago.
- Main sx: Asymptomatic.
- Known dx or relevant hx: HTN.
- Investigations performed to date: BP monitoring.
- Prev tx: ACE inhibitor.
**Other**
- PMHx/PSHx: IHD, HTN, Appendectomy 2005.
- FHx/SHx/Vax hx: Father – IHD. Smoker 20/day. Flu vaccine last year.
**On Exam**
Obs: BP 140/90 | HR 72 | T 37.2 | SpO2 98% RA
HS: Dual, no murmurs.
RS: Clear.
**Management Plan**
- Ix ordered – FBC, UEC, CRP.
- Referred to Cardiology.
- Follow-up in 2 weeks for results and review.
- Symptomatic advice: Rest, fluids, paracetamol for fever.
- Safety net advice: Seek urgent review if SOB, chest pain, or worsening symptoms.
(You must follow this template exactly. Do not invent drug names or treatment classes. Use only bold for issue headings, never quotes. Do not use full sentences in Management Plan — use dot points and abbreviations. Do not repeat contextual advice unless safety netting is explicitly stated. Do not retain examination lines unless findings are present. Use this structure and match formatting strictly. No narrative phrasing, no placeholder padding, no hallucinated meds or results.)
**History**
(Use all available standard medical abbreviations such as URTI, IHD, HTN. Structure all content using • dot bullets. Avoid narrative style. Separate distinct issues using a hash. Do not use full sentences.)
**[# Issue heading]**
- [Onset, duration, and any precipitating factors] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Main sx and associated features] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Known dx or relevant hx] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Investigations performed to date] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Prev tx] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(Repeat this structure for each issue.)
**Other**
- PMHx/PSHx: [Past medical and surgical hx] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- FHx/SHx/Vax hx: [Family, social, or vaccination hx if relevant] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit this section completely.)
**On Exam**
(Only include this section if any relevant findings are documented. Omit the entire section if all findings are blank. Only include lines for systems that were actually examined. Use standard shorthand.)
Obs: BP [/] | HR [] | T [] | SpO2 [_% RA] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
JVP: [JVP findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
HS: [Heart sounds] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
RS: [Respiratory findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Abd: [Abdominal findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
MSE: [Mental state findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Other: [Other relevant physical exam findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Management Plan**
(Use - dash points. Write in concise shorthand. Do not list results or drug names. Do not list specialist names. Do not use full sentences. **Do not name medications or drug classes. All pharmacological info must be documented in History only.**)
- [Ix ordered – e.g. FBC, UEC, CRP, ECG, swabs] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Referred to [specialist type only] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Follow-up timeframe and reason] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Symptomatic advice if given] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Safety net advice if provided] (Only include 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 it completely. Use as many lines or paragraphs as needed to capture all relevant information from the transcript.)
