General Patient Note - Small issue

(Never add direct quotations throughout this note). **<u>Date:</u>** [Date of Consultation](Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely. Listen for the date mentioned as the day of consultation, do not automatically use the current date) **_[Patient Age in numbers]y/o [male or female], now with [summary of tthe acute issue during this presentation]._** (This should be a brief, one-line summary of the main reason for the consultation, framed as 'signs and symptoms consistent with...' the likely issue.) **<u>Medical History:</u>** [Patient Age in numbers]y/o [male or female]: (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.) # [Medical comorbidities]: [Well or poorly controlled][on which medications][known complications][latest bloods]. (Only add one comorbidity per hashtag. Also add past surgeries with indications therefor or complications afterwards in this list. With cardiovascular conditions or comorbidities I will mention known target-organ-damage (TOD) which should be noted. Where relevant I wil mention latest blood results to give context to chronic management. Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely. For example - # Hypertensive: Well controlled on Amlodipine 10mg OD with known chronic renal failure. Latest GFR 54.) # Allergies: [spesific allergy and severity if mentioned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.) **<u>Presenting Complaint:</u>** "Patient now presents with" [mention presenting complaint]. (Please discribe the presenting complaint in the following order of characteristics: Issue/ Duration/ Associated issues/ Important negatives/ Alleviating or exacerbating factors. Describe what is mentioned in clinical terms and do not use direct speech-to-text unless specifically asked for. Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely.) **<u>Social History:</u>** (Only include if relevant and explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely.) **<u>Family Medical History: </u>** # [Family member designation]: [History]. (Include relevant medical conditions, complications, and cause of death if relevant. Add each family member mentioned separately. Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely). **<u>Physical examination:</u>** (please fill the relevant clinical information to the following categories, but keep all categories even with findings normal as mentioned by myself. Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely.) BP: [blood pressure reading in numbers followed by mmHg] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.) HR: [heart rate in numbers followed by bpm] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.) SATS: [percentage in number followed by % and either on room air or on oxygen] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.) T: [either apyrexic or the number I give] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.) HGT: [Glucose in number followed by mmol/L. If not mentioned just say N/A for not applicable] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else state 'N/A'.) Hb: [Hb in number followed by g/dL. If not mentioned just say N/A for not applicable] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else state 'N/A'.) <u>General appearance:</u> [Mention general comments on appearance in this section. Use concise, telegraphic phrases where appropriate. Listen carefully if palpable lymphnodes are mentioned. Also comment on build.] (If nothing specific mentioned in the transcript, contextual notes or clinical note, state "Appears stable with no jaundice, pallor, cyanosis, clubbing, lymphadenopathy, or distress at rest". If any findings are mentioned, only list those findings and do not include the default normal statement.) (Always mention all systems and all findings mentioned - even if normal or negative) (Do not include the descriptions of the abbreviations given below - it is purely for your understanding) <u>Respiratory system:</u> [Mention quality of air entry and which adventitious sounds are present. Mention whether patient is distressed or comfortable on room air. Listen for GAEB (good air entry bilaterally) which I will typically say when no respiratory pathology present.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.) <u>Cardiovascular system:</u> [Mention comments made on cardiac sounds and if any abnormal sounds where present. Mention if the patient is in acute failure or not. Comment on the quality and rhythm of pulses and in which limbs they where present as well as if there was a delay.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.) <u>Abdominal system:</u> [Mention SNT (soft and non-tender) if no pathology noted. If the main complaint is abdominal related mention in the following order. Abdomen distended or not. Any obvious pathology noted on inspection. Abdomen soft or hard and if peritonism is present is it local or generalised (spesifically add if one of the following or both is positive: rebound tenderness or percussion tenderness). Note masses palpable (in the case of a hernia mention if reducable or not and if there is a positive pressure test.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.) <u>Neurological system:</u> [GCS level, PEARL or not (Pupils equal and reactive to light), orientation, cranial nerve fallout, focal or global motor or sensory fallout, other relevant neurological signs.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.) <u>Other relevant systems:</u> (please add system in bullet point format followed by : and then details. For example: Musculoskeletal: detail) (Options: Musculoskeletal, ENT, Breasts, Genitourinary, Perianal, Dermatological). (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.) **<u>Assessment:</u>** [summative assessment of acute diagnosis/reason for consultation and results]. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely.) **<u>Plan:</u>** 1. <u>Biochemistry requested:</u> [List of all requested biochemistry tests]. (Please fill as mentioned. If nothing mentioned add "Nill".) (Fill tests in groups in bullet point format in here only if results discussed. Group all relevant results together, for example - Lipid profile: Elevated Triglyceride level of 3.3 mmol/L, but good amount HDL and normal total cholesterol. Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.) 2. <u>Imaging requested:</u> [List of all requested imaging]. (Please fill as mentioned. If nothing mentioned add "Nill".) (If results discussed add here in bullet point form, for example - Chest X-Ray: No consolidation, masses, or areas of hypo perfusion. Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.) 3. <u>Counselled on:</u> [Details of patient counselling]. (Please fill as mentioned. If nothing mentioned add "N/A" These are typically the things where I say I discussed [the spesific thing] with the patient. please listen carefulle and add all detail I discussed with the patient or counselled the patient on. Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else state 'N/A'.) 4. <u>Management initiated:</u> (Please add in bullet points any changes made to medications, any new medications added (put acute or chronic in brackets), any injections administered. Please add where I say I gave the patient medication. Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.) 5. <u>Patient to return:</u> [Return instructions, which could be one of these options: As needed; On a set date; In a set duration; If a specific complication, progression, or new symptoms arise, or if no resolution of symptoms by a set date.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit completely.) **<u>Tasks to be created:</u>** [List of tasks such as referrals, letters, results to check, information to request and review.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely.)