Subjective:
- Reason for visit: Patient presents today with a chief complaint of a persistent cough and shortness of breath for the past two weeks.
- Current GP: Dr. Emily Carter at the Riverside Clinic.
- Symptom details: Cough is dry and hacking, worse at night. Shortness of breath occurs with minimal exertion. No chest pain.
- Aggravating and relieving factors: Cough is aggravated by cold air and exercise. Relieved slightly by rest.
- Progression: Symptoms have gradually worsened over the past two weeks.
- Previous episodes: Patient reports a similar cough last winter, which resolved with rest and over-the-counter medication.
- Impact on daily activities: Shortness of breath limits ability to walk the dog and perform household chores.
- Associated symptoms: Mild fatigue.
Past Medical History:
- Contributing medical/surgical history: Asthma diagnosed at age 10, well-controlled with inhaler. No surgeries.
- Relevant social history: Non-smoker. Drinks alcohol occasionally. Works as a teacher.
- Relevant family history: Mother has a history of asthma.
- Exposure history: No known environmental exposures.
- Immunisation history/status: Up-to-date with flu and COVID-19 vaccinations.
- Other relevant information: Patient is concerned about the possibility of pneumonia.
- Obstetric/menstrual history: Not applicable.
- Bowel health: Regular bowel movements.
- Sleep: Reports difficulty sleeping due to coughing.
- Metabolic health: No known metabolic concerns.
- Chronic pain: No chronic pain.
- Histamine-related conditions: Occasional seasonal allergies.
- Diet: Balanced diet.
- Work: Works as a teacher.
- Hobbies: Enjoys gardening.
Objective:
- Vitals: Temperature 37.2°C, Pulse 88 bpm, Respirations 20/min, BP 130/80 mmHg, SpO2 96% on room air.
- Examination findings: Chest auscultation reveals mild wheezing in the left lung. No other significant findings.
- Investigations with results: Chest X-ray: No evidence of pneumonia. Spirometry: FEV1 75% predicted.
Assessment:
- Likely diagnosis: Exacerbation of asthma.
- Differential diagnosis: Bronchitis, upper respiratory tract infection.
Plan:
- Investigations planned: Repeat spirometry in 2 weeks.
- Treatment planned: Increase in inhaled corticosteroid dose. Prescribe a short course of oral steroids. Advise on asthma action plan.
- Other actions: Provide patient education on asthma management. Schedule follow-up appointment in 2 weeks. Advise patient to return if symptoms worsen.
Date: 1 November 2024
Subjective:
- Reason for visit: [mention reasons for visit, chief complaints such as requests, symptoms etc] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; else omit completely. Write as a single bullet point.)
- Current GP: [mention current GP] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; else omit completely. Write as a single bullet point.)
- Symptom details: [mention duration, timing, location, quality, severity, and context of complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; else omit completely. Write as a single bullet point.)
- Aggravating and relieving factors: [list anything that worsens or alleviates the symptoms, including self-treatment attempts and their effectiveness] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; else omit completely. Write as a single bullet point.)
- Progression: [describe how the symptoms have changed or evolved over time] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; else omit completely. Write as a single bullet point.)
- Previous episodes: [detail any past occurrences of similar symptoms, including when they occurred, how they were managed, and the outcomes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; else omit completely. Write as a single bullet point.)
- Impact on daily activities: [explain how the symptoms affect the patient's daily life, work, and activities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; else omit completely. Write as a single bullet point.)
- Associated symptoms: [mention any other symptoms (focal or systemic) that accompany the reasons for visit or chief complaints] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; else omit completely. Write as a single bullet point.)
Past Medical History:
- Contributing medical/surgical history: [list past conditions, surgeries, investigations, or treatments relevant to the current complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; else omit completely. Write as bullet points.)
- Relevant social history: [include social factors relevant to the current complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; else omit completely. Write as bullet points.)
- Relevant family history: [include any relevant family medical history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; else omit completely. Write as bullet points.)
- Exposure history: [mention any relevant environmental, occupational or lifestyle exposures] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; else omit completely. Write as a single bullet point.)
- Immunisation history/status: [include immunisation history where relevant] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; else omit completely. Write as a single bullet point.)
- Other relevant information: [any additional subjective info relevant to the case] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; else omit completely. Write as bullet points.)
- Obstetric/menstrual history: [mention relevant reproductive health history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; else omit completely. Write as bullet points.)
- Bowel health: [mention any bowel symptoms or patterns] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; else omit completely. Write as a single bullet point.)
- Sleep: [mention sleep issues] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; else omit completely. Write as a single bullet point.)
- Metabolic health: [mention relevant metabolic concerns] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; else omit completely. Write as a single bullet point.)
- Chronic pain: [mention presence and history of chronic pain] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; else omit completely. Write as a single bullet point.)
- Histamine-related conditions: [mention conditions such as sinusitis, hayfever, headaches, menorrhagia, dysmenorrhoea, insomnia, anxiety] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; else omit completely. Write as bullet points.)
- Diet: [mention diet-related information] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; else omit completely. Write as a single bullet point.)
- Work: [mention work situation or employment status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; else omit completely. Write as a single bullet point.)
- Hobbies: [mention any relevant recreational or leisure activities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; else omit completely. Write as a single bullet point.)
Objective:
- Vitals: [recorded vital signs] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; else omit completely. Write as a single bullet point.)
- Examination findings: [physical or mental state examination findings, including system-specific assessments] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; else omit completely. Write as bullet points.)
- Investigations with results: [completed investigations and their results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; else omit completely. Write as bullet points. Do not include planned investigations here.)
Assessment:
- Likely diagnosis: [mention any working diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; else omit completely. Write as a single bullet point.)
- Differential diagnosis: [mention alternative possible diagnoses] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; else omit completely. Write as bullet points.)
Plan:
- Investigations planned: [any tests or investigations ordered] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; else omit completely. Write as bullet points.)
- Treatment planned: [any medications, physical therapies, procedures or treatment protocols planned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; else omit completely. Write as bullet points.)
- Other actions: [any counselling, patient education, referrals or additional tasks] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; else omit completely. Write as bullet points.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, or 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, leave the relevant placeholder or section blank. Use as many bullet points as needed to capture all the relevant information from the transcript.)