Consult

Subjective: Patient Identification: [age and gender of patient with main diagnosis] Reason for consult: [Specific complaint or reason for the visit.] (Only include specific complaint or reason for the visit if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Main issues: (Make a concise numbered list of main medical issues.) 1. [main medical problem] 2. [next medical problem] 3. [next medical problem] (Only include if explicitly mentioned in the transcript, context or clinical notes; else omit completely) Medications: (Make a numbered list of current medications with dosages and frequency of administration. Only include list of current medications and dosages if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Allergies: [Specific allergies, especially to medications.] (Only include specific allergies if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Immunizations: [Up-to-date status of immunizations and any recent vaccinations.] (Only include immunization status and recent vaccinations if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Make-a-Wish : [ Mention if Make a Wish plans have been made or wish already granted] Code Status: [Mention code status if discussed] (Only included specific code status if explicitly mentioned) Community MD: [Name of primary physician in the community] Equipment at Home: [List of physical aids patient has at home] Financial Supplements: [list of financial supplements family, specify whether family has not applied, has applied but hasn't yet received, or is already receiving the supplement) History of Present Illness: [Detailed description of illness including onset, duration, character, and associated symptoms.] (Only include history of present illness if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Past Medical History: [Perinatal history, previous illnesses, developmental milestones and any concerns related to growth or development] (Make a numbered list and only include details on conditions explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Admissions/ER Visits: [date of and reason for previous Emergency Room visits] (Only include specific emergency room visits if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Surgeries: [date of and reason for previous surgeries] (Only include specific surgeries if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Family History: [Family history including hereditary conditions or other diseases within the family.] (Only include family history if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Psychosocial History: [Social history including living situation, exposure to tobacco smoke, family dynamics, safety at home, schooling/pre-schooling, family conflicts, parental mental health issues, financial issues, respite services, support from CLSC or other community agencies, adaptation of the home and family vehicle.] (Only include psychosocial history if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Review of Systems: Neuro: [Details of neurological status including muscle weakness, ability to walk or jump or run or climb stairs, seizures] Resp: [Details of respiratory issues or symptoms such as snoring, shortness of breath, asthma, pneumonia, respiratory illness] ORL/Audiology: [Details of otorhinolaryngeal issues such as drooling, ear infections, deafness] Cardio: [Details of cardiac issues such as palpitations, chest pain, cardiology assessments such as echocardiograms, ECGs] Nutrition/GI: Nutrition: [Diet and nutritional details including breastfeeding, formula, solids introduction, and any dietary restrictions or concerns such as choking with feeds as well as presence of gastrointestinal issues such as vomiting, regurgitation, constipation, diarrhea .] (Only include diet and nutrition details if they are explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) GU: [Details of genitourinary issues such as incontinence, phimosis, undescended testicles] Endo: [Details of endocrine issues such as hypothyroidism, hypoglycemia] Heme: [Details of hematological issues such as anemia] Derm: [Details of skin issues such as eczema or acne] MSK: [Details of musculoskeletal issues such as scoliosis, dislocated hips, contractures] Rehab/Equipment: [Details of equipment used including manual or electric wheelchair, walker, orthotics, corset] School: [Details of name of school, grade, special educational program, favourite class, adaptations in the school] Development/Behaviour: [Details of mood, presence or not of behaviour issues such as ADHD, autism] General: Sleep: {Details of falling asleep, staying asleep] Dentistry: [Details of frequency of tooth brushing, cavities, dental visits and treatments] Ophthalmology: [Details of vision issues, last optometrist or ophthalmologist visit] Physical Examination: Vital Signs: [Temperature, Pulse, Respiratory rate, Blood Pressure, Oxygen Saturation.] (Only include vital signs if they have been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Weight: [current weight in kg and last weight in kg with date] Height: [current height in centimeters and last height in centimeters with date] General Appearance: [Observations of general appearance, any signs of distress, fluid status eg. capillary refill or fontanelle size.] (Only include general appearance if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Skin: [Skin examination findings including rashes, lesions, or any dermatological concerns.] (Only include skin examination if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) HEENT: [Head, Eyes, Ears, Nose, Throat, Neck examination findings.] (Only include Head, Eyes, Ears, Nose, Throat examination findings if they have been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Chest/Lungs: [Chest/lung examination including breath sounds, respiratory effort, upper airway sounds.] (Only include chest/lung examination findings if they have been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Cardiovascular: [Cardiovascular examination findings including heart sounds, murmurs.] (Only include heart sounds and murmurs if they have been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Abdomen: [Abdominal examination findings including tenderness, organomegaly.] (Only include abdominal findings if they have been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Genitourinary: [ Genitourinary examination including descent of testicles, phimosis, tanner staging of pubic hair, testicular size in boys, breast size in girls] Musculoskeletal: [Musculoskeletal examination including joint mobility, any deformities, scoliosis, hip dislocation, contractures.] (Only include musculoskeletal findings if they have been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Neurological: [Neurological examination including reflexes, muscle strength, cranial nerve examination.] (Only include neurological findings if they have been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) [Any other examination findings, grouped by system where possible](Only include other examination findings if they have been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Investigations: - [Completed investigations with results] (you must only include completed investigations with results if they have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely. Planned or ordered investigations should be documented under the Management Plan section.) Impression and Plan: (Make a numbered list of medical issues with a concise description of the current status of that issue followed by the treatment, referral and/or follow-up plan for each issue described next to it.) [ First diagnosis or main issue with treatment, referral and/or follow up] (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 to include 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.)