Date: 1 November 2024
Dr. Eleanor Vance
123 High Street
Anytown, AB1 2CD
Dear Dr. Vance,
Re: John Smith, DOB: 12/03/1960, NHS Number: 1234567890, 456 Oak Avenue, Anytown, AB1 2CD
Diagnosis: Ischaemic Cardiomyopathy, Hypertension
Other Past Medical History: Previous myocardial infarction in 2018, Percutaneous Coronary Intervention (PCI) to the left anterior descending artery (LAD) in 2018. History of type 2 diabetes mellitus.
Medications: Aspirin 75mg once daily, Bisoprolol 5mg once daily, Ramipril 10mg once daily, Atorvastatin 40mg nocte, Metformin 1000mg twice daily.
Medication allergies and intolerances: No known drug allergies.
It was my pleasure to see Mr. Smith in Cardiology Clinic today. He is being seen due to worsening shortness of breath and chest pain.
Clinical History:
Mr. Smith presents with increasing shortness of breath on exertion over the past 2 months, now occurring with minimal activity. He also reports intermittent chest pain, described as a pressure sensation, lasting for approximately 5-10 minutes and relieved by rest. The chest pain is not associated with any specific triggers.
Social History:
Mr. Smith is a retired accountant. He is a former smoker, having quit 5 years ago, with a 30 pack-year history. He drinks alcohol occasionally, approximately 1-2 units per week. He engages in light exercise, such as walking, for 30 minutes, three times a week. He lives with his wife.
Family History:
Father died at age 70 from a myocardial infarction. Mother has hypertension.
Examination Findings:
Blood pressure: 140/85 mmHg, Heart rate: 72 bpm, regular. Respiratory rate: 16 breaths per minute. Oxygen saturation: 98% on room air. Cardiovascular examination: Mildly elevated JVP. Auscultation revealed a grade 2/6 systolic murmur at the apex. No peripheral oedema.
Investigations:
ECG: Shows evidence of previous inferior myocardial infarction. Echocardiogram: Left ventricular ejection fraction (LVEF) of 35%, with regional wall motion abnormalities. Stress test: Positive for inducible ischaemia. Blood tests: Elevated BNP (1200 pg/mL).
Assessment:
1. Ischaemic Cardiomyopathy: Significant left ventricular dysfunction (LVEF 35%) with evidence of ongoing ischaemia.
2. Hypertension: Blood pressure is not adequately controlled.
Management Plan:
* Optimise medical therapy: Increase Bisoprolol to 10mg once daily. Review Ramipril dose. Consider adding a loop diuretic if symptoms worsen.
* Lifestyle modifications: Encourage regular exercise and a low-sodium diet.
* Further investigations: Consider coronary angiography to assess for revascularisation.
* Follow-up: Cardiology clinic follow-up in 4 weeks.
* Referral: Referral to cardiac rehabilitation program.
Date: [current date] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[recipient GP name and address] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Dear Dr. [GP surname] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Re: [patient full name, date of birth, NHS number and address] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Diagnosis: [list primary cardiac diagnosis and any secondary diagnoses] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Other Past Medical History: [list relevant past medical conditions, previous cardiac events, interventions, or surgeries] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Medications: [list current medications including dose, frequency, and recent changes] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Medication allergies and intolerances: [document any medication allergies or intolerances] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
It was my pleasure to see [patient's name] in Cardiology Clinic today. They are being seen due to [short summary of major cardiology diagnosis/issue]. (Only include if explicitly mentioned in transcript, context or clinical note, else omit sentence entirely.)
Clinical History:
[document presenting symptoms, duration, severity, aggravating and relieving factors, and progression of cardiac symptoms]
(Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Social History:
[include relevant lifestyle factors such as smoking status, alcohol intake, exercise habits, occupation, and living arrangements]
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Family History:
[document any family history of cardiac disease or relevant conditions]
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Examination Findings:
[document vital signs, cardiovascular examination findings, and any other relevant physical examination findings]
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Investigations:
[list investigations performed including ECG, echocardiogram, stress tests, blood tests, cardiac imaging, and their results]
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Assessment:
[provide interpretation of findings, diagnosis, disease severity, and prognosis]
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Management Plan:
[detail treatment plan including medication changes, lifestyle modifications, further investigations, follow-up arrangements, and referrals to other services]
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(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.) (where mentioned use the correct pronouns for the patient.).