Problem List and Past Medical History:
- Fatty liver disease
- Gastroesophageal reflux disease (GERD)
- Abdominal pain
- Hypertension
Medications:
- Atorvastatin 20mg daily
- Omeprazole 20mg daily
- Lisinopril 10mg daily
Social History:
- Smokes 10 cigarettes per day
- Drinks alcohol socially, approximately 2-3 units per week
Allergies:
- Penicillin
Investigations results
- Liver function tests (LFTs) show elevated ALT and AST.
- Abdominal ultrasound reveals fatty liver.
- Upper endoscopy shows mild oesophagitis.
Summary:
Mr. Smith, a [insert age] year old male, presents with a history of fatty liver disease, GERD, and abdominal pain. He is currently taking atorvastatin, omeprazole, and lisinopril. Social history includes smoking and occasional alcohol consumption. Allergies include penicillin. Investigations reveal elevated liver enzymes and fatty liver on ultrasound.
Management Plan and Follow-Up:
- Continue current medications as prescribed.
- Advised to stop smoking.
- Advised to reduce alcohol consumption.
- Follow-up appointment in 3 months to review liver function tests and symptoms.
- Referral to a dietician for dietary advice.
Problem List and Past Medical History:
- [list symptoms or medical problems] (only include list symptoms or medical problems if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely. when making list place hepatology/liver and gastrointestinal problems first)
Medications:
- [list medications and doses] (only include list medications and doses if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Social History:
- [list social history] (only include list social history if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Allergies:
- [list allergies] (only include list allergies if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Investigations results
(List Investigations results as per transcript or dictation
Summary:
[summary of history in formal sentences] (only include summary of history in formal sentences if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Management Plan and Follow-Up:
- [list management plan and follow-up] (only include list management plan and follow-up if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely. each point in the list should be a concise complete sentence in easy to understand language for patient)
(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 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.)