RG Consult Note

```plaintext =========================== HISTORY OF PRESENT ILLNESS =========================== [Name, age and gender of the patient, followed by a list of existing medical conditions. State "presented with" and then list presenting symptoms. If a condition has been diagnosed, state "and was found to have". Cardiology conditions should be listed first. Include important disease modifiers in parentheses; for example, atrial fibrillation should include CHAD VASC Score and current anticoagulation, and heart failure (HFpEF and HFrEF) should include ejection fraction as EF.] [Summary of events that occurred this hospitalization leading up to the consult.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Summary of this provider's conversation with the patient at bedside.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Duration, timing, location, quality, severity, and context of the complaint.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [A list of 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; otherwise omit completely.) [Description of how the symptoms have changed or evolved over time.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Details of 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; otherwise omit completely.) [Explanation of 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; otherwise omit completely.) [Any other symptoms (focal and systemic) that accompany the reasons for consult and chief complaints.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Summary of any prior hospitalizations.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Summary of any relevant events that occurred at the last outpatient cardiology appointment, including recent medication changes, investigations obtained, referrals, and other actions.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Any other relevant subjective information.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Summary of positive findings on review of systems, only if not already mentioned, followed by negative findings on review of systems.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) ================================================== MEDICATIONS AND ADDITIONAL PAST MEDICAL HISTORY ================================================== CURRENT MEDICATIONS: - [In-hospital or current medications, with doses and frequency if provided.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) RELEVANT HOME MEDICATIONS: - [Outpatient medications, with doses and frequency if provided.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) CARDIOVASCULAR CONDITIONS: - [Current and past cardiovascular conditions, including valvular issues, heart failure, arrhythmias, coronary artery disease, and any cardiac procedures with dates and locations. If a condition was found on an imaging study, list the condition with the study name and date in parentheses afterwards.] (This section must be included but only include conditions that are explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) OTHER NON-CARDIAC CONDITIONS: - [Non-cardiac past medical and surgical history relevant to the reasons for consult and chief complaints.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) RELEVANT FAMILY AND SOCIAL HISTORY: - [Social history that may be relevant to the reasons for consult and chief complaints, including where the patient lives, who they live with, whether they have family nearby, children, functional status including ADLs, need for assistive devices like wheelchairs, canes or walkers, tobacco use, alcohol use, drug use, pets, diet, and exercise.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Family history of heart disease that may be relevant to the reasons for consult and chief complaints.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) ========================================== VITALS AND PHYSICAL EXAMINATION FINDINGS ========================================== VITAL SIGNS: [Vital signs listed as one line with data points separated by commas, including temperature (T), heart rate (HR), respiratory rate (RR), blood pressure (BP), and pulse oximetry (SpO2), along with the amount and device for oxygen delivery if relevant, in the order T, HR, RR, BP, SpO2, Oxygen Delivered.] (If not explicitly mentioned in the transcript, contextual notes or clinical note, enter "Unremarkable.") PHYSICAL EXAMINATION: - [Physical or mental state examination findings, including system-specific examinations, listed as multiple distinct lines for each system with the following system-based headings: General, HEENT, Cardiovascular, Pulmonary, Abdominal, Neurologic, Musculoskeletal, Skin.] (If not explicitly mentioned in the transcript, contextual notes or clinical note, default to the following format: General: A&Ox3, in no acute distress HEENT: Moist mucous membranes CV: Normal rate and rhythm; no JVD Pulm: Normal work of breathing Abd: Non-distended Neuro: Grossly intact MSK: No LE edema Skin: No bruising or rashes on exposed skin) ================================================== LABS, IMAGING, AND RELEVANT CARDIOVASCULAR DATA ================================================== LABS: - [Laboratory results from the current hospitalization, as well as baselines if provided.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) IMAGING: - [Imaging results from the current hospitalization.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) TELEMETRY: [All reported telemetry findings with dates, locations, and key findings.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) ECG: - [Reported ECG/EKG findings with dates, locations, and key findings.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) PATCH MONITOR OR DEVICE INTERROGATION: - [Reported patch monitor, Ziopatch, loop recorder, or electrophysiologic device (e.g. ICD, pacemaker) findings with dates, locations, and key findings.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) ECHOCARDIOGRAM: - [Reported TTE, TEE, or other echocardiogram findings with dates, locations, and key findings.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) CATH: - [Reported cardiac catheterization findings with dates, locations, and key findings.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) STRESS TESTING: - [Reported exercise or pharmacologic stress test findings with dates, locations, and key findings.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.) =================================== ASSESSMENT AND RECOMMENDATIONS =================================== ACTIVE CARDIOLOGY PROBLEM(S): 1. [State the reason (or reasons if multiple) for the consult, which could be a chief complaint, symptoms, a test finding, or a specific request from another service.] ASSESSMENT: [Begin by summarizing the patient's relevant history (e.g. one-liner) and presentation as well as the active cardiology issue(s) that are discussed. Limit the relevant cardiology history to four conditions or fewer which are most relevant to the case, and do not include medical history that is not relevant to the presentation in the one-liner. The one-liner should be completed by the phrase 'for which cardiology was consulted'. Thereafter, provide a complete and thorough summary of the physician's assessment for this patient, including the likely diagnosis if stated and any differential diagnoses. The summary should include some rationale or explanation for the recommendations listed below.] RECOMMENDATIONS: [If more than one condition is being addressed, specifically list each condition by name in bold with a '#' preceding the condition and without a preceding bullet point, and indent the bullet points for each action item below each condition; for example, if the problem is HFrEF exacerbation, list as '#HFrEF exacerbation'. Include important disease modifiers in parentheses in the condition title when applicable. If only one condition is being addressed, the name of the condition should be omitted altogether. Individual bullet points for any planned investigations, tests, treatments, or other actions such as outpatient referrals, along with their justifications should be listed below each relevant condition if multiple conditions are present, or as a single list below the 'Summary of recommendations' header directly if only one condition is present.] (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.)