Social History
Patient transferred from Auckland, moved to Whangarei in 2020, current occupation: Registered Nurse, living arrangements: lives with her partner.
Anthropometric Data
Patient’s height – 165 cm
Patient’s weight – 70 kg
Patient’s waist circumference – 85 cm
Patient’s body mass index (BMI) – 25.8
Vital Signs
Blood pressure – 130/80 mmHg
Pulse – 78 bpm, regular
Allergies and Immune Status
Patient allergies: Penicillin (causes rash)
Whether the patient is immune deficient – no
Surgical History
Appendectomy in 2010.
Family History
Father: Type 2 diabetes. Mother: History of hypertension.
Medications
Lisinopril 10mg daily, Paracetamol as needed.
Medical History
Hypertension, diagnosed 2022.
Social History
[Transferred from where, when the patient moved to Whangarei, current occupation, living arrangements including who the patient lives with] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Anthropometric Data
[Patient’s height – \ht cm] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Patient’s weight – \wt kg] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Patient’s waist circumference – \wc cm] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Patient’s body mass index (BMI) – \bmi] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Vital Signs
[Blood pressure – \bp] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Pulse – \p and whether it is regular or irregular] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Allergies and Immune Status
[Patient allergies, including any known medication allergies] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Whether the patient is immune deficient – yes or no] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Surgical History
[Past surgeries if any, listed] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Family History
[List any relevant family history including: first-degree relatives with diabetes (type 1 or type 2), cancers, or cardiac history (especially under 50 years of age)] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Medications
[List of prescribed medications] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Include over-the-counter, purchased medications, and supplements if applicable] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Medical History
[List of any long-term conditions or relevant medical history] (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 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.)