Subjective:
- Reason for visit or chief complaint: Patient presents today for medication review and counselling.
- Symptom characteristics: N/A
- Symptom modifiers and self-management: N/A
- Symptom progression: N/A
- Previous episodes: N/A
- Impact on daily activities: N/A
- Associated symptoms: N/A
Past Medical History:
- Relevant medical and surgical history: Hypertension, Hyperlipidemia, Type 2 Diabetes Mellitus.
- Relevant social history: Smokes 10 cigarettes per day. Drinks alcohol occasionally. Lives alone.
- Relevant family history: Father with history of Coronary Artery Disease.
- Exposure history: N/A
- Immunisation history: Up-to-date with influenza and pneumococcal vaccines.
- Other relevant subjective information: Patient reports some difficulty managing medications.
Objective:
- Vital signs: Blood Pressure: 140/90 mmHg, Pulse: 78 bpm, Oxygen Saturation: 98% on room air.
- Physical or mental examination findings: Alert and oriented. Appears to understand the medication regimen.
- Investigations with results: HbA1c: 8.2%, LDL Cholesterol: 140 mg/dL.
Assessment:
- Diagnosis: Uncontrolled Hypertension, Hyperlipidemia, Type 2 Diabetes Mellitus.
- Differential diagnosis: N/A
Plan:
- Recommendations and counselling: Provided education on medication adherence, lifestyle modifications (diet, exercise, smoking cessation), and potential side effects. Reviewed proper administration techniques. Encouraged patient to use a pill organiser. Discussed importance of regular blood glucose monitoring.
- Investigations planned: Repeat HbA1c in 3 months. Lipid panel in 3 months.
- Treatment planned: Adjusted medication dosages for hypertension and diabetes. Provided a prescription for a nicotine replacement therapy.
- Other actions such as referrals or follow-up: Scheduled a follow-up appointment in 1 month to assess medication adherence and efficacy. Referred to a smoking cessation program.
Subjective:
- [Reason for visit or chief complaint] (State the primary reason for the consultation, such as symptoms, requests, or concerns raised by the patient. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise leave blank.)
- [Symptom characteristics] (Include duration, timing, location, quality, severity, and context of the complaint. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise leave blank.)
- [Symptom modifiers and self-management] (Include factors that worsen or relieve symptoms, and any self-treatment attempts and their effectiveness. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise leave blank.)
- [Symptom progression] (Describe how the symptoms have changed over time. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise leave blank.)
- [Previous episodes] (Include details of any prior similar episodes, how they were managed, and outcomes. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise leave blank.)
- [Impact on daily activities] (Describe how the issue affects daily functioning, including work, home, or physical activity. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise leave blank.)
- [Associated symptoms] (List any related or systemic symptoms that accompany the main complaint. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise leave blank.)
Past Medical History:
- [Relevant medical and surgical history] (Include any contributing past illnesses, surgeries, treatments, or relevant findings. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise leave blank.)
- [Relevant social history] (Include lifestyle, occupation, substance use, or social determinants of health relevant to the presenting complaint. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise leave blank.)
- [Relevant family history] (Include any hereditary or familial conditions relevant to the current presentation. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise leave blank.)
- [Exposure history] (Include occupational, travel, or environmental exposures relevant to the complaint. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise leave blank.)
- [Immunisation history] (Include immunisation status or relevant vaccines. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise leave blank.)
- [Other relevant subjective information] (Include any additional information that provides useful context. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise leave blank.)
Objective:
- [Vital signs] (Include values for temperature, pulse, blood pressure, oxygen saturation, etc. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise leave blank.)
- [Physical or mental examination findings] (Summarise findings from the physical or mental state exam, organised by body system or clinical relevance. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise leave blank.)
- [Investigations with results] (List only completed investigations with available results. Do not include investigations that are planned or pending. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise leave blank.)
Assessment:
- [Diagnosis] (State the confirmed diagnosis or clinical impression. Do not infer or suggest. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise leave blank.)
- [Differential diagnosis] (List any alternative diagnoses under consideration. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise leave blank.)
Plan:
- [Recommendations and counselling] (Summarise the clinician’s advice, education or counselling given during the visit. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise leave blank.)
- [Investigations planned] (Include tests or diagnostic procedures to be ordered. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise leave blank.)
- [Treatment planned] (Include any medications, therapies, or interventions recommended. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise leave blank.)
- [Other actions such as referrals or follow-up] (Include any referrals, follow-up plans, or allied health involvement. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise leave blank.)
(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.)
