Diagnoses:
- Angina
- Hypertension
- Hypercholesterolemia
Drug Therapy:
- Aspirin 75mg once daily
- Atorvastatin 20mg nocte
- Ramipril 2.5mg once daily
List any significant allergies or drug intolerances
- Penicillin allergy
Plan and Recommendations:
The patient will continue on current medication. I have advised the patient to continue with regular exercise and a low-fat diet. I have advised the patient to stop smoking. I have arranged for a follow-up appointment in 3 months to review his symptoms and medication. I have also referred the patient to a cardiac rehabilitation program.
Thank you for referring this 68-year-old male with chest pain.
History of Presenting Symptoms: The patient presents with a history of intermittent chest pain, which is worse on exertion and relieved by rest. The patient reports the chest pain has been occurring for the past 3 months. The patient denies any shortness of breath or palpitations. Prior cardiac history includes a previous myocardial infarction 5 years ago, treated with percutaneous coronary intervention (PCI).
Cardiovascular Risk Factors: The patient is a current smoker, smoking 20 cigarettes per day. The patient has a history of type 2 diabetes, managed with diet and metformin. The patient's blood pressure is well-controlled on medication. His most recent cholesterol profile showed an LDL of 3.5 mmol/L. Family history of cardiovascular disease includes his father who had a myocardial infarction at age 65.
Past Medical History: The patient has a history of hypertension and hypercholesterolemia.
Examination Findings: Heart rate 72 bpm, BP 140/80 mmHg, saturations 98% on room air. JVP not elevated. Cardiac auscultation revealed a normal S1 and S2, with no murmurs or added sounds. Carotids were normal. Chest was clear to auscultation.
Resting ECG: The resting ECG showed evidence of previous inferior myocardial infarction.
Conclusions: Based on the history and examination, the patient's chest pain is likely due to angina. Investigations requested include a repeat ECG and a stress test. Medication changes include increasing the dose of Ramipril to 5mg once daily. The patient has been advised to stop smoking and continue with regular exercise and a low-fat diet. Follow-up is planned in 3 months.
Diagnoses:
- [list each diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank. This should include relevant past medical history - cardiac first then other medical history. List at top the primary presenting symptom or symptoms.)
Drug Therapy:
- [list each medication, including dose, frequency, and route of administration] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
[If dictated] List any significant allergies or drug intolerances (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Plan and Recommendations:
[describe the plan for each diagnosis, including any follow-up appointments, referrals, lifestyle modifications, and other recommendations. Do not use bullet points.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Begin main letter with: (Thank you for referring this [Age] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [gender] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [occupation if stated] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) with [describe the presenting symptom or purpose of the review in a short phrase] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.). Alternatively if self-referred begin letter with "Thank you for arranging a review and [describe the presenting symptom or purpose of the review in a short phrase]" (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.))
(Detail the history of the presenting symptoms, prior cardiac history if relevant) (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
(Detail cardiovascular risk factors as follows - smoking history, presence of diabetes, hypertension, cholesterol profile followed in the same paragraph the family history of cardiovascular disease. Describe family history as a sentence: male parental side, then maternal, then sibling history.) (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Describe relevant past medical history if mentioned. Do not use bullet points.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Describe examination findings [The heart rate, then BP, then saturations, then JVP, cardiac auscultation, carotids, chest signs. Do not comment if any aspect of examination is omitted or not mentioned.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[If described Resting ECG: "The resting ECG .... Describe ECG findings if undertaken or if mentioned in letter from a copy from the patient or referrer, use precise medical terminology and abbreviations."] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Final paragraph should list the conclusions drawn from the history and likely diagnoses or differential diagnoses (This should be based on the conversation and never made up by Heidi.) [Detail investigations requested, followed by medication changes made. Medication changes should be highlighted in the drug list as changes also. Provide details of patient recommendations and advice and follow up plans. Do not use bullet points.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
(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.)
