Medical notes summary for General Practitioner
Presenting Complaint:
Patient presents today with a three-day history of a worsening cough, described as dry and non-productive. The patient reports associated symptoms of mild fatigue and a low-grade fever. No chest pain or shortness of breath is reported.
Past Medical History:
The patient has a history of seasonal allergies, managed with over-the-counter antihistamines. No previous respiratory illnesses or hospitalisations.
Immediate Management Plan:
Advised the patient to rest and increase fluid intake. Recommended over-the-counter cough suppressant as needed. Prescribed no medication. Advised to return if symptoms worsen or if they develop chest pain or difficulty breathing. Scheduled a follow-up appointment in one week.
[describe the presenting complaint, including the duration, key characteristics of the symptoms, and any relevant associated symptoms or events, in concise medical prose] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[summarise any relevant past medical history or previous similar episodes pertinent to the current presentation, including any prior investigations or treatments, in concise medical prose] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[detail the immediate management plan, including any advice given, medications prescribed or recommended, and any follow-up arrangements or investigations planned, in concise medical prose] (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.)(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.)