Medical Issues:
* Migraine with aura
* Cervical dystonia
* Anxiety
Current Medication:
* Sumatriptan 50mg, as needed for migraine
* Botulinum toxin injections, every 3 months for cervical dystonia
* Sertraline 50mg daily
Progress:
Patient reports a reduction in migraine frequency and severity since the last review. The patient has had 2 migraine attacks in the last month, compared to 4-5 per month previously. The botulinum toxin injections continue to provide good relief from cervical dystonia symptoms, with improved neck posture and reduced muscle spasms. The patient reports stable mood and anxiety symptoms on current medication.
Investigations:
* MRI brain and cervical spine: Stable, no new findings.
Examination:
* Cranial nerves: Intact.
* Motor: Normal strength in all limbs.
* Sensory: Intact to light touch and pinprick.
* Reflexes: 2+ and symmetrical.
* Cervical dystonia: Mild residual torticollis, improved since last injection. Time since last dose of dopa medication: N/A
Impression:
* Stable migraine with aura.
* Well-controlled cervical dystonia.
* Anxiety, stable.
Plan:
* Continue current medication regimen.
* Schedule botulinum toxin injections every 3 months.
* Review migraine diary in 3 months.
* Continue to monitor anxiety symptoms.
Patient Education:
* Reviewed migraine triggers and management strategies.
* Discussed the importance of adherence to medication for cervical dystonia.
* Reinforced the importance of regular follow-up appointments.
"Should you have any further questions regarding the above patient, please do not hesitate to contact me."
Medical Issues:
[diagnoses and active medical conditions] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points. Avoid unnecessary repetition.)
Current Medication:
[current medications and dosages] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Progress:
[summary of clinical progress since last visit including new treatments started, updates on investigations, and clinical symptoms] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs.)
[document relevant negative findings if described] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in bullet points.)
[additions to social, allied health, or mental health history] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph form.)
Investigations:
[results of recent investigations such as blood tests, MRI, or others done since last review] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Examination:
[relevant findings on neurological examination] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points. if no new findings dictated, write "nil new findings". If Parkinson's disease is mentioned, include time since last dose of dopa medication. Write as bullet points.)
Impression:
[summary of current clinical impressions or working diagnoses] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Plan:
[outline key management points, actions, or referrals planned] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points. Be brief and concise. Maintain clear formatting and spacing to improve readability.)
Patient Education:
[summary of education provided to the patient during the consultation] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
"Should you have any further questions regarding the above patient, please do not hesitate to contact me."
(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 include 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.)
(Replace "jaw clenching" with "bruxism".)
(Do not document costs of procedures or treatments discussed during the review.)
(Listen for GON block, which stands for Greater Occipital Nerve Block.)
(Listen for cervical dystonia terms such as laterocollis, torticollis, anterocollis, retrocollis, anterocaput, retrocaput, laterocaput, lateral shift.)