Thank you for your care of Sarah.
**Admission Details**
- Chief Complaint: Chest pain and shortness of breath.
- Diagnosis: Suspected pulmonary embolism.
**Treatment Provided**
- Interventions: IV access established, oxygen administered, ECG performed, blood drawn for investigations, CT pulmonary angiogram performed.
- Medications Administered: 5000 units of Heparin IV bolus.
**Results of Investigations**
- Pathology: D-dimer elevated at 1.5 mg/L. Troponin within normal limits.
- Imaging: CT pulmonary angiogram confirmed a small pulmonary embolism in the right lower lobe.
**Patient's Condition at Discharge**
- Stable, chest pain resolved, saturating well on room air.
- Vital Signs: BP 120/80 mmHg, HR 88 bpm, SpO2 98% on room air.
**Discharge Instructions**
- Medications: Enoxaparin 1mg/kg subcutaneously twice daily for 7 days, then review with GP.
- Activity Level: Avoid strenuous activity for 1 week.
- Warning Signs: Worsening chest pain, shortness of breath, leg swelling, or any signs of bleeding.
- Follow-Up: Review with GP in 7 days for repeat blood tests and assessment.
Kind regards,
Nurse Emily Carter
Registered Nurse
1234567
Thank you for your care of [patient's first name].
**Admission Details**
- Chief Complaint: [Brief description of the presenting issue]
- Diagnosis: [Final diagnosis or clinical impression]
**Treatment Provided**
- Interventions: [List of treatments and interventions provided in the ED]
- Medications Administered: [Details of any medications given, including dosages]
**Results of Investigations**
- Pathology: [Key results from blood tests, urine tests, etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Imaging: [Findings from X-rays, CT scans, MRIs, etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Patient's Condition at Discharge**
- [General condition at the time of discharge]
- Vital Signs: [Latest recorded vital signs]
**Discharge Instructions**
- Medications: [Prescriptions given at discharge, with dosages and instructions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Activity Level: [Recommended level of activity] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Dietary Advice: [Any advised dietary changes or restrictions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Wound Care: [Instructions for wound care] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Warning Signs: [Signs & symptoms to watch for that would necessitate a return to the hospital or further medical attention] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Follow-Up: [Details of any scheduled follow-up appointments] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Kind regards,
[Clinician Name]
[Designation / Role]
[Provider Number or Contact Information]
(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.)