General Practitioner-Vorlage
Bradford VTS GP Concise Consult
Eine professionelle General Practitioner-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
Looking for a quick and efficient way to document patient consultations? This 'Bradford VTS GP Concise Consult' template is perfect for General Practitioners. It's designed to capture essential information in a structured, bullet-point format, covering history, examination, impression, and plan. This template helps GPs create clear and concise notes, saving time and ensuring all key details are recorded. With Heidi, this template can be quickly populated from your consultation transcript, streamlining your workflow and improving documentation accuracy. This template is ideal for busy GP practices, helping to create comprehensive medical records efficiently.
Vorlagenvorschau
HISTORY
- reports LBP 6wks, dull ache radiating L leg
- 6wks duration, worse prolonged sitting/standing, relieved by rest, no trauma
- OTC paracetamol gives partial relief, tried heat pack – no benefit
- gradually worsening since onset
- similar episode 2y ago, settled with physio
- limits ability to walk >30 mins, avoids lifting
- reports numbness L foot, denies SOB, CP, fever
PMH
- PMH: HTN dx 2018, on lisinopril
- SH: retired accountant, non-smoker, occasional ETOH, lives w/ wife
- FH: father – IHD
- Exposure: nil relevant
- Immunisations: UTD
- Other: nil
EXAMINATION
- obs stable: HR 72, BP 134/82, afebrile
- gait: mild limp L
- spine: tender L4-L5, ↓ROM lumbar flex
- neuro: ↓LT sensation L5 dermatome, SLR +ve @45° L
- blds: normal
- XR lumbar: mild degen changes
IMPRESSION
1. L radiculopathy 2° degen disc disease
2. chronic LBP
3. DDx: disc herniation, spinal stenosis
PLAN
1. LBP/radiculopathy
- DDx: disc herniation, spinal stenosis
- planned: MRI lumbar spine
- to continue OTC analgesia (paracetamol + ibuprofen)
- referral: physio (starts next wk)
2. HTN
- to continue lisinopril 10mg OD
- no new concerns, BP within target
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