Name: John Smith
Thank you for referring John to me. Please find feedback from our session below.
Diagnosis:
Chronic lower back pain secondary to lumbar facet joint arthropathy.
Plan:
Recommend a course of physiotherapy.
Prescribe a short course of oral analgesics.
Arrange a follow-up appointment in four weeks.
History:
John, a 55-year-old male, reports a history of lower back pain for the past six months. He is a retired accountant. The pain began gradually without any specific injury, and is located in the lower back, radiating to the right buttock. The pain is described as a deep ache, and is aggravated by prolonged sitting and standing. There is no associated leg pain or neurological symptoms. The pain is worst in the evenings and is not relieved by rest. The pain score is currently 6/10, and has been around 7/10 over the past three days, and 5/10 at night.
Functional limitations:
John reports difficulty with prolonged sitting and standing, impacting his ability to enjoy social activities. He is able to manage his personal care, walking, and sleeping without significant difficulty. He has an Oswestry Disability Index score of 28.
Treatment to date:
John has been taking over-the-counter paracetamol and ibuprofen, with limited relief. He has not received any formal physiotherapy or other interventions.
Red Flags:
There are no neurological red flags.
Review of systems:
John reports no dizziness, vertigo, balance difficulties, fine motor issues, migraines or headaches, unrefreshed sleep, cognitive changes, or systemic symptoms.
Musculoskeletal history:
John has a history of mild neck pain, which resolved with conservative management.
Past medical history:
John has a history of hypertension, well-controlled with medication. He has no surgical history, family history of back pain, or known allergies.
Allergies:
No known allergies.
Medications:
Lisinopril 10mg daily.
Patients impression and expectation:
John understands that his back pain is likely related to age-related changes. He is concerned about the impact on his mobility and quality of life. He hopes to find a treatment plan that will reduce his pain and improve his function. Anxiety; 4, Depression; 2.
Examination:
Weight 85kg, height 178cm, BMI 26.8. Vital signs are within normal limits. John is alert and oriented. Examination reveals tenderness to palpation over the lumbar facet joints. Range of motion is reduced in flexion and extension. Straight leg raise is negative bilaterally. Neurological examination is normal.
Imaging:
Lumbar spine X-rays show mild degenerative changes at the L4-L5 and L5-S1 levels.
Assessment:
Chronic lower back pain secondary to lumbar facet joint arthropathy. Differential diagnosis includes lumbar discogenic pain and spinal stenosis.
Management:
Arrange lumbar facet joint injections.
Prescribe tramadol 50mg as required for pain.
Refer to physiotherapy for core strengthening exercises.
Advise on ergonomic modifications at home and work.
Causal Link:
No direct causal link can be made.
Many thanks again for the referral.
Name: [Patient’s first and last name]
Thank you for referring [Patient’s first name] to me. Please find feedback from our session below.
Diagnosis:
[Insert concise diagnosis and how it relates to the injury mentioned] (Only include if explicitly mentioned in transcript, context or clinical note. List each diagnosis on a new line. No bullet points. End each line with a full stop.)
Plan:
[Insert brief plan to manage condition or injury, excluding post-operative management] (Only include if explicitly mentioned in transcript, context or clinical note. List each plan on a new line. No bullet points. End each line with a full stop.)
History:
[Mention patient’s age, current or previous occupation if available. Describe site of main pain complaint, how and when it began, and whether it is injury-related, including specific date or time frame if stated. Describe the character of the pain and if there is radiation, include the nature of radiation, such as deep ache or superficial burning. Include any associated symptoms such as stiffness or nausea. Describe the temporal pattern including best/worst times and sleep interruption. Include factors that aggravate or relieve the pain. Mention the severity of pain, including pain score now, over the past three days, and at night.] (Only include if explicitly mentioned in transcript, context or clinical note. Write in full sentences in paragraph format without bullet points.)
Functional limitations:
[Detail patient’s ability to manage personal care, lifting, walking, sleeping, social activities, travel, standing and sitting. Include Oswestry Disability Index score if available.] (Only include if explicitly mentioned in transcript, context or clinical note. Write in full sentences in paragraph format without bullet points.)
Treatment to date:
[Detail any treatment received to date, including medications, physiotherapy or other relevant interventions.] (Only include if explicitly mentioned in transcript, context or clinical note. Write in full sentences in paragraph format without bullet points.)
Red Flags:
[Describe any neurological red flags such as progressive or severe neurological deficits, pain radiating to other areas, loss of sensation or function, back pain following trauma, unexplained weight loss, fever, history of cancer, intravenous drug use, constant or night pain, age-related risk, or long-term steroid use or immunosuppression.] (Only include if explicitly mentioned in transcript, context or clinical note. Write in full sentences in paragraph format without bullet points.)
Review of systems:
[Include dizziness, vertigo, balance difficulties, fine motor issues, migraines or headaches, unrefreshed sleep, cognitive changes, and systemic symptoms such as cardiac, respiratory, renal or bowel symptoms, skin rashes or night sweats.] (Only include if explicitly mentioned in transcript, context or clinical note. Write in full sentences in paragraph format without bullet points.)
Musculoskeletal history:
[Detail any previous musculoskeletal issues relevant to the current presentation.] (Only include if explicitly mentioned in transcript, context or clinical note. Write in full sentences in paragraph format without bullet points.)
Past medical history:
[Include past medical and surgical history, family history, social history, and allergies.] (Only include if explicitly mentioned in transcript, context or clinical note. Write in full sentences in paragraph format without bullet points.)
Allergies:
[List allergies, nature of reaction, and any medication sensitivities.] (Only include if explicitly mentioned in transcript, context or clinical note. Write in full sentences in paragraph format without bullet points.)
Medications:
[List each current medication on a new line] (Only include if explicitly mentioned in transcript, context or clinical note. No bullet points. Do not begin lines with a hyphen. End each medication with a full stop.)
Patients impression and expectation:
[Summarise the patient’s understanding of their condition in their own words, including any fears, concerns or expectations of the consultation and treatment process. Include anxiety and depression scores if available in format: Anxiety; [score], Depression; [score]] (Only include if explicitly mentioned in transcript, context or clinical note. Write in full sentences in paragraph format without bullet points.)
Examination:
[Include weight, height and BMI if available. Note vital signs if assessed. Describe general physical or mental state, and include specific examination findings relevant to the presenting complaint.] (Only include if explicitly mentioned in transcript, context or clinical note. Write in full sentences in paragraph format without bullet points.)
Imaging:
[Detail any radiology results including interpretations relevant to the current complaint.] (Only include if explicitly mentioned in transcript, context or clinical note. Write in full sentences in paragraph format without bullet points.)
Assessment:
[Provide a clinical assessment, including the most likely diagnosis and rationale based on subjective and objective findings. Include differential diagnosis only if explicitly stated.] (Only include if explicitly mentioned in transcript, context or clinical note. Write in full sentences in paragraph format without bullet points.)
Management:
[Investigations planned such as imaging or pathology if applicable.] (Only include if explicitly mentioned in transcript, context or clinical note. Write in full sentences in paragraph format without bullet points.)
[Medical treatment plans including medications, dosages, expected outcomes, and any notes on opioid or risk-related prescribing where relevant.] (Only include if explicitly mentioned in transcript, context or clinical note. Write in full sentences in paragraph format without bullet points.)
[Non-pharmacological interventions such as physiotherapy, occupational therapy, CBT or acupuncture if applicable.] (Only include if explicitly mentioned in transcript, context or clinical note. Write in full sentences in paragraph format without bullet points.)
[Procedural or interventional plans such as injections or ablations if discussed.] (Only include if explicitly mentioned in transcript, context or clinical note. Write in full sentences in paragraph format without bullet points.)
[Lifestyle advice relevant to activity, ergonomics, or pain modulation strategies.] (Only include if explicitly mentioned in transcript, context or clinical note. Write in full sentences in paragraph format without bullet points.)
[Referrals to other services if indicated.] (Only include if explicitly mentioned in transcript, context or clinical note. Write in full sentences in paragraph format without bullet points.)
[Planned follow-up appointments or monitoring intervals.] (Only include items that are explicitly mentioned in transcript or context. Each item should begin on a new line with a full stop, but never begin with a hyphen or bullet.)
Causal Link:
[Describe any stated causal relationship between the current condition and an identified injury, including whether a direct link can be made.] (Only include if explicitly mentioned in transcript, context or clinical note. Write in full sentences in paragraph format without bullet points.)
Many thanks again for the referral.
(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 section blank. Use a full stop at the end of each line within a list. Never use - at the start of a list. Always refer to the patient using their first name.)
