Dear Dr. Eleanor Vance,
As you know Mrs. Evelyn Reed is a 72-year-old female with the following past medical history: Hypertension, Hyperlipidemia, and a history of a myocardial infarction in 2018.
Past medical history:
1. Cardiac Related History:
* Myocardial Infarction (2018): Successfully treated with PCI and stent placement. Currently on dual antiplatelet therapy.
* Hypertension: Well-controlled on medication.
* Hyperlipidemia: Managed with statin therapy.
* Atrial Fibrillation: Paroxysmal, managed with medication.
2. Non-Cardiac History:
* Osteoarthritis: Affecting both knees, managed with conservative measures.
Social History: Mrs. Reed is retired and lives with her husband. She enjoys gardening and light walking. She has a strong social support network, including family and friends. Her symptoms of occasional chest pain limit her ability to walk long distances. She does not smoke and drinks alcohol occasionally.
Active medications:
* Aspirin 75mg daily
* Bisoprolol 5mg daily
* Atorvastatin 20mg daily
* Warfarin 2mg daily
* Ramipril 5mg daily
Family History: Father died at age 78 from a stroke. Mother has hypertension. One sibling has a history of coronary artery disease.
On review today: Mrs. Reed presents today with intermittent chest pain, described as a pressure-like sensation, occurring with exertion and relieved by rest. The pain started approximately two months ago and has been increasing in frequency and intensity. She denies any associated symptoms such as shortness of breath, nausea, or diaphoresis. She reports no recent changes in her medications or lifestyle.
Review of Systems:
* Cardiovascular: Reports intermittent chest pain with exertion.
* Respiratory: Denies shortness of breath, cough, or wheezing.
* Gastrointestinal: Reports no abdominal pain, nausea, or vomiting.
* Neurological: Denies headaches, dizziness, or syncope.
Examination: Blood pressure 138/82 mmHg, heart rate 72 bpm, regular. Cardiac auscultation reveals a regular rhythm with no murmurs, rubs, or gallops. Lungs are clear to auscultation bilaterally. Peripheral pulses are palpable and equal bilaterally. There is no peripheral edema.
Investigations:
* ECG: Shows sinus rhythm with no acute ST-T wave changes.
* Echocardiogram: Scheduled for next week.
Impression and management:
In addressing the patient's issues:
1. Unstable Angina:
* Impression: Mrs. Reed's presentation of intermittent chest pain with exertion, along with her history of coronary artery disease, raises concern for unstable angina.
* Plan:
1. Continue current medications.
2. Schedule an echocardiogram to assess cardiac function and rule out any new wall motion abnormalities.
3. Consider a stress test if the echocardiogram is unremarkable.
4. Educate the patient on the importance of rest and avoidance of strenuous activities that provoke chest pain.
5. Instruct the patient to seek immediate medical attention if chest pain worsens or occurs at rest.
Follow up:
* Follow up in two weeks to review the results of the echocardiogram and discuss further management.
Additional follow-up instructions: Please contact me if the patient's symptoms worsen before the follow-up appointment.
Thank you very much for involving me in the care of Mrs. Evelyn Reed. Please do not hesitate to contact me should you have any questions.
Dear [REFERRING PHYSICIAN],
As you know [PATIENT NAME] is a [AGE] [GENDER] with the following past medical history: [Past medical history details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Past medical history:
[CARDIAC RELATED HISTORY followed by non-cardiac history] (write in numbered list with subheadings if detailed summary of one issue) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Social History: [SOCIAL HISTORY DETAILS] (write this section as a narrative and do not use bullet points. Please include day to day activities, social support network, occupation, limitations of symptoms on daily life) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Active medications:
[ACTIVE MEDICATIONS] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Family History: [FAMILY HISTORY DETAILS] (importantly screen for cardiovascular disease and age of onset. Remove if not discussed) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
On review today: [HISTORY OF PRESENTING ILLNESS DETAILS] (write this section as a narrative and do not use bullet points. Aim to keep prose specific to symptoms. Avoid including repeat of any past medical history or investigations listed in other sections unless relevant. Please be detailed in descriptions.) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[REVIEW OF SYSTEMS DETAILS] (please write this section as a prose. Include negatives if the patient is asked) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Examination: [PHYSICAL EXAMINATION FINDINGS] (do not use bullet points in this section. Write this specific section as a narrative) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Investigations:
[INVESTIGATION RESULTS] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Impression and management: (use bullet points for any medication or investigations requested as part of the plan, otherwise do not.)
In addressing the patient's issues:
[ASSESSMENT AND PLAN DETAILS] (create numbered list, with each issue have its own issue and impression in a narrative paragraph followed by a numbered list of the management plan for each issue. For example: "1. The patient has multifactorial breathlessness with heart failure being a significant contributing factor. The plan for this: 1. commence furosemide 20mg 2. update echocardiogram etc) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Follow up:
[FOLLOW-UP PLAN DETAILS] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[ADDITIONAL FOLLOW-UP INSTRUCTIONS] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Thank you very much for involving me in the care of [PATIENT NAME]. Please do not hesitate to contact me should you have any questions.
[ADDITIONAL NOTES] (Only include if explicitly mentioned in the 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, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)